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AccessConnect for Zydelig
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Phone
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(844)622-2377
Fax:
(855)553-8672
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Eligibility
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Must have no prescription coverage for needed medication. Medicare Part D patients are eligible, but contact program fro details. Income requirements not disclosed. Must be a US resident and treated by a US licensed healthcare provider. |
| Who Can Apply
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Call for prescreening and have application faxed. Return application via fax. Call for decision which could take up to 10 days. |
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Required
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Diagnosis/medical criteria required to be medically Necessary as determined by a Doctor. Doctor must complete and sign application. Patient must complete application, sign, attach copies of proof of income, residency and other requested documentation. |
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Supply
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Up to 30 day supply. Patient contacts pharmacy for refills. Contact the program for refill limit details. New application to be completed yearly. |
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Ship To
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Ships to Patient's home within 4-10 business days. |
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Note
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The ZYDELIG QuickStart Program provides a free 30-day supply for eligible patients who face an insurance coverage delay of more than 5 business days.
This program also provides copay assistance for insured patients. |
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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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| Zydelig tablet |
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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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| Zydelig tablet |
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