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Patient Assistance Information

 
2 Programs for Benlysta injection
 
 
Benlysta Gateway Co-Pay Assistance Program

PO Box 222173
Charlotte, NC 28222
Phone : (877)423-6597
Fax: (877)850-9901
Eligibility
> May have private insurance; must not be government funded. Medicare Part D patients are not eligible for this program. Income information not required. Must live in US, DC or Puerto Rico.
Who Can Apply
> Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms that are sent via fax. Return application via fax. Patient and Doctor are notified within 24-48hrs.
Required
> Diagnosis/Medical Criteria not specified. Doctor & patient must complete and sign application.
Supply
> Amount/supply not applicable. Refills are good for 1 year. Refill limit not applicable. New application must be completed yearly.
Ship To
> Shipping location not applicable.
Note
> The BENLYSTA Copay Card will pay 100% of your out-of-pocket costs for BENLYSTA up to a total of $9,000 annually.
 
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.
 
Benlysta injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Benlysta Gateway Co-Pay Assistance Program
(Requires Acrobat Reader
 
 
Benlysta Gateway Patient Assistance Program

PO Box 222173
Charlotte, NC 28222
Phone : (877)423-6597
Fax: (877)850-9901
Eligibility
> Must not have any insurance or be eligible for state or federal funded healthcare. Medicare Part D patients are not eligible for this program. Income must be at or below 500% of FPL. Must live in US, DC or Puerto Rico.
Who Can Apply
> Call to have application faxed, mailed or download from website. Return application via fax or mail. Patient and Doctor are notified of decision within 24-48hrs.
Required
> Diagnosis/Medical Criteria not specified. Doctor must complete and sign application. Patient must complete application, sign and attach a copy of proof of income.
Supply
> Amount/supply varies. Company contacts Doctor to arrange refills. No refill limit. New application must be complete yearly.
Ship To
> Ships to Doctor's office or infusion site within 2 business days.
Note
>
 
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.
 
Benlysta injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Benlysta Gateway Patient Assistance Program
(Requires Acrobat Reader