| |
Diplomat's Co-Pay Assistance Navigator Program
|
Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
:
(877)977-9118
Ext 89864
Fax:
(810)282-0176
|
|
Eligibility
|
| > |
Insurance determined case by case. Medicare Part D patients are eligible for this program. Income requirements determined case by case. Must be a US resident. Must have medically appropriate condition/diagnosis. |
| Who Can Apply
|
| > |
Patient or Doctor may call to receive application via fax or mail. May also complete application online. Application is to be mailed or faxed back to company. |
|
Required
|
| > |
Doctor's action will be discussed with patient and Doctor after request is received. Patient must complete application, sign and provide annual income information. Proof of income may be requested by program at any time. Patient and/or Doctor are notified of decision within 1-2 business days. |
|
Supply
|
| > |
Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
|
Ship To
|
| > |
Once approved medication is shipped to Patient's home within 2 business days. |
|
Note
|
| > |
Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie |
| |
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
|
| Erivedge capsule |
| |
| |
|
|
| |
Genentech Access to Care Foundation (Erivedge)
|
PO Box 2807
South San Francisco, CA 94083
Phone
:
(888)249-4918
Fax:
|
|
Eligibility
|
| > |
This program is intended for Patients with no prescription coverage for needed medication. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider. |
| Who Can Apply
|
| > |
Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form. Application received via fax, mail, or downloaded from website. Return application via fax or mail. Patient will be notified of decision. |
|
Required
|
| > |
Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income. |
|
Supply
|
| > |
Amount/supply varies. Refill process and limit not specified. New application must be completed yearly. |
|
Ship To
|
| > |
Ship to Patient's home, doctor's office, hospital or pharmacy. |
|
Note
|
| > |
|
| |
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
|
| Erivedge capsule |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Genentech Access to Care Foundation (Erivedge) |
(Requires Acrobat Reader) 
|
| |
|
|