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Benlysta Gateway Patient Assistance Program
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PO Box 222173
Charlotte, NC 28222
Phone
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(877)423-6597
Fax:
(877)850-9901
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Eligibility
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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
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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
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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. |
Supply
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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
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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. |
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 Patient Assistance Program |
(Requires Acrobat Reader)
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