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Patient Assistance Information

 
 
 
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