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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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| Sancuso transdermal patch |
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Patient Rx Solutions Program - Sancuso
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Patient Rx Solutions Sancuso
Patient Assistance Proram PO Box 325
Florham Park, NJ 07932
Phone
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866-325-8231
Fax:
866-694-2546
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Eligibility
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This program provides brand name medications at no or low cost to patients that have no prescription coverage for the needed medication. Patients with Medicare Part D are not eligible. Patients must be at or below 300% of the federal poverty level and must be a US citizen or legal resident. |
| Who Can Apply
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Patients and healthcare providers can call to have an application faxed, mailed or it can be downloaded. |
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Required
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Doctors must complete a section of the application, sign and attach a prescription. Patients must complete a section of the application, sign and attach proof of income. The application can then be faxed or mailed. |
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Supply
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Varies |
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Ship To
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Doctor's office |
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Note
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This Company also offers a Reimbursement Program.
SANCUSO Copay Assistance Card Program: Save up to $150 on each prescription after paying the first $20. Each SANCUSO card is good for 24 fills, up to 4 patches per fill up to a maximum of 48 patches, subject to your prescription coverage.
Contact program for Spanish application. |
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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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| Sancuso transdermal patch |
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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 |
(Requires Acrobat Reader) 
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