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Patient Assistance Information

 
1 Program for Hectorol injection
 
 
Renassist Patient Assistance Program (RPAP)


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Phone : (800)847-0069 Ext opt.2
Fax: (877)363-6732
Eligibility
> Insurance requirements *See Additional Information section below Those with Part D Eligible?*See Additional Information Section Below Income requirements Vary. **See below for details
Who Can Apply
> Call for application to be faxed, emailed, or mailed or download from website. Return application via email, fax or mail. Must be a US citizen or possess a valid green card.
Required
> Diagnosis/Medical Criteria not required. Doctor must complete section and sign. Patient must complete section, sign, attach required documents. Dialysis facility notified of acceptance or denial within 4 weeks.
Supply
> Up to 3 months supply. Refill form sent with each supply. Maximum of 3 refills through one year from date on original prescription. New application needed 1 year from date of prescription on original application.
Ship To
> Ship to Doctor's office or dialysis unit.
Note
> For the medication Renagel: Contact program for more information. For the medication Hectorol: If on dialysis, the patient can not be receiving Medicare Part B. For the medication Renvela: If the patient is Medicare eligible with income below 150% of the FPL, the patient must apply for the Limited Income Subsidy (LIS) and be denied. Proof of denial for LIS must be submitted along with the application. Patients must meet AKF financial criteria. Patients can be in the 90-day waiting period for Medicare without drug coverage, ineligible for Medicare, or have Medicare with no prescription coverage.
 
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.
 
Hectorol injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Renassist Patient Assistance Program (RPAP)
(Requires Acrobat Reader