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Diplomat's Co-Pay Assistance Navigator Program
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Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
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(877)977-9118
Ext 89864
Fax:
(810)282-0176
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Eligibility
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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
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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. |
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Required
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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. |
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Supply
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Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
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Ship To
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Once approved medication is shipped to Patient's home within 2 business days. |
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Note
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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 |
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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.
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| Nilandron |
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Rx Outreach Medications
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PO Box 66536
St Louis, MO 63166
Phone
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(888)796-1234
Fax:
(800)875-6591
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Eligibility
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Patients with insurance, including Medicare Part D, are eligible. Patients must be at or below 300% of the federal poverty level and reside in the US. |
| Who Can Apply
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Patients or healthcare providers can call to have an application mailed or faxed. It can also be downloaded. |
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Required
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Patients must complete a section and sign. Doctors must provide the patient with a prescription. The application can then be faxed and the prescription can be sent by E-Prescribe. |
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Supply
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Varies |
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Ship To
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Doctor's office or patient's home |
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Note
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Some medications are available for a fee of $20 for up to a 180 day supply.
Check the Rx Outreach website for the exact price and most current medication list.
Contact Program for Spanish Application(s)/Form(s). |
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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.
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| Nilandron |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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