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Benlysta Gateway Co-Pay Assistance Program
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PO Box 222173
Charlotte, NC 28222
Phone
:
(877)423-6597
Fax:
(877)850-9901
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Eligibility
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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
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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. |
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Required
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Diagnosis/Medical Criteria not specified. Doctor & patient must complete and sign application. |
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Supply
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Amount/supply not applicable. Refills are good for 1 year. Refill limit not applicable. New application must be completed yearly. |
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Ship To
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Shipping location not applicable. |
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Note
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The BENLYSTA Copay Card will pay 100% of your out-of-pocket costs for BENLYSTA up to a total of $9,000 annually. |
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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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| Benlysta injection |
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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) 
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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. |
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Required
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Diagnosis/Medical Criteria not specified. Doctor must complete and sign application. Patient must complete application, sign and attach a copy of proof of income. |
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Supply
|
| > |
Amount/supply varies. Company contacts Doctor to arrange refills. No refill limit. New application must be complete yearly. |
|
Ship To
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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)
|
| |
|
|