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Patient Assistance Information

 
2 Programs for Synribo powder; subcutaneous
 
 
CORE Patient Assistance Program

PO Box 7588
Overland Park, KS 66207
Phone : 888-587-3263
Fax: 866-676-4073
Eligibility
> Patients must have no prescription coverage for the needed medication, be at or below 500% of the Federal Poverty Level, have a medically appropriate diagnosis/condition and be a citizen or legal resident.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. It can also be downloaded.
Required
> Doctors must complete a section and sign. Patients must complete a section, sign, attach a copy of proof of income, and attach front and back copy of insurance card.
Supply
> Not specified
Ship To
> Doctor's office
Note
> Contact program for Spanish application.
 
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.
 
Synribo powder; subcutaneous
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
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.
 
Synribo powder; subcutaneous