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Patient Assistance Information

 
2 Programs for Rebif syringe; subcutaneous
 
 
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.
 
Rebif syringe; subcutaneous
 
 
 
MS Lifelines


,
Phone : (877)447-3243
Fax:
Eligibility
> Insurance requirements determined case by case. Medicare part D eligibility varies. Income requirements for this program have not been disclosed. Must be a US resident.
Who Can Apply
> Applicant must call for prescreening and application will be sent to the Patient via mail. Patient will be notified of decision within 7-10 business days.
Required
> Must have MS. Doctor must fax in prescription. Patient must complete application, sign, attach proof of income and other requested documentation.
Supply
> Amount/supply varies. Company contacts Patient to arrange refills. Refill limit not specified. New application and documentation required yearly.
Ship To
> Medication will be shipped to Patient's home once approved. Shipped same day.
Note
> Program does not use financial guidelines or an application for the first year of enrollment. They encourage patients to call the toll free number for assistance. Eligibility determined on a case-by-case basis.
 
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.
 
Rebif syringe; subcutaneous