ABBOTT LABORATORIES
Name Of Program
Patient Assistance Program
Physician Requests Should Be Directed To
Abbott Laboratories
Uninsured Patient Program
200 Abbott Park Road, D31C, J23
Abbott Park, IL 60064-6163
(800) 222-6885 (option 1)
Product(s) Covered By Program
Most Abbott Laboratories pharmaceutical products
Eligibility
Abbott Laboratories patient assistance program is available to outpatients who do not have insurance reimbursement for prescriptions and are not eligible for governmental assistance programs (i.e., Medicaid, ADAP).
Other Program Information
The licensed prescribers office contacts Abbott Laboratories to request an application on the behalf of a patient. An application is sent to the prescriber for completion. Upon receipt of a completed application we will send the prescriber notification regarding the patient's eligibility. If approved, medication will only be shipped to the prescriber's office.
AGOURON PHARMACEUTICALS, INC.
Name Of Program
Agouron Patient Assistance Program
Physician Requests Should Be Directed To
Patient Assistance Program
(888) 777-6637
Product(s) Covered By Program
VIRACEPT® (nelfinavir mesylate), RESCRIPTOR®(delavirdine mesylate)
Eligibility
Eligibility is determined on a case-by-case basis and takes into consideration an individual's circumstances. Potential applicant or representative may contact the VAP at 1-888-777-6637 between 9am and 6pm EST. Applications are mailed to the physician's office.
Other Program Information
Once eligibility is determined, a monthly supply is sent to the physician's office. Enrollees must re-enroll every four months.
ALZA PHARMACEUTICALS
Name Of Program
Indigent Patient Assistance Program
Physician Requests Should Be Directed To
Indigent Patient Assistance Program
ALZA Pharmaceuticals
1250 Bayhill Drive, Suite 300
San Bruno, CA 94066
(800) 577-3788
Product(s) Covered By Program
Bicitra, Concerta, Ditropan, Ditropan XL, Elmiron, Mycelex, Neutra-Phos, Neutra-Phos-K, PolyCitra, PolyCitra-K, Progestasert, Testoderm, Urispas
Eligibility
Eligibility is determined by ALZA Pharmaceuticals and is based on patient's insurance status and income level. Patients must be ineligible for any other third-party reimbursement or support program to apply for the Indigent Patient Assistance Program.
Other Program Information
The physician must request an Indigent Patient Assistance application from ALZA Pharmaceuticals.
AMGEN INC.
Name Of Program
SAFETY NET® Program for EPOGEN®
Physician Requests Should Be Directed To
Amgen SAFETY NET® Program for EPOGEN®
(800) 272-9376
Product(s) Covered By Program
EPOGEN® (Epoetin alfa)
Eligibility
For patients on dialysis only. Amgen's SAFETY NET® Program is designed to assist those patients who are medically indigent (patients may be uninsured or underinsured). Eligibility is based on patient's insurance status and income level. To enroll a patient, providers should contact the Amgen SAFETY NET® Program by calling (800) 272-9376.
Other Program Information
Providers apply on behalf of the patient. Any dialysis center, physician, hospital or home dialysis supplier may sponsor a patient by applying to the program on his or her behalf. The program is based on a 12-month patient year rather than on a calendar year. Phone-in or written applications are acceptable for program enrollment.
Name Of Program
SAFETY NET® Program for INFERGEN®
Physician Requests Should Be Directed To
Amgen SAFETY NET® Program for INFERGEN®
(888) 508-8088
Product(s) Covered By Program
INFERGEN® (Interferon alfacon-1)
Eligibility
For patients with chronic hepatitis C only. Amgen's SAFETY NET® Program is designed to assist those patients who are medically indigent. Eligibility is based on patient's insurance status and income level. To enroll a patient, the patient or provider should contact the Amgen SAFETY NET® Program by calling (888) 508-8088.
Other Program Information
Providers may enroll a patient or the patient may enroll him or herself. Any administering physician, hospital, community pharmacy or home health company may sponsor a patient by applying to the program on his or her behalf. The program is based on a 12-month patient year rather than on a calendar year. Phone-in or written applications are acceptable for program enrollment.
Name Of Program
SAFETY NET® Program for NEUPOGEN®
Physician Requests Should Be Directed To
Amgen SAFETY NET® Program for NEUPOGEN®
(800) 272-9376
Product(s) Covered By Program
NEUPOGEN® (Filgrastim)
Eligibility
Amgen's SAFETY NET® Program is designed to assist those patients who are medically indigent (patients may be uninsured or underinsured). Eligibility is based on patient's insurance status and income level. To enroll a patient, providers should contact the Amgen SAFETY NET® Program by calling (800) 272-9376.
Other Program Information
Providers apply on behalf of the patient. Any administering physician, hospital, home health company, or community pharmacy may sponsor a patient by applying to the program on his or her behalf. The program is based on a 12-month patient year rather than on a calendar year. Phone-in or written applications are acceptable for program enrollment.
ASTRAZENECA
Name Of Program
AstraZeneca LP Patient Assistance Program
Physician Requests Should Be Directed To
AstraZeneca Patient Assistance Program
(800) 355-6044
Product(s) Covered By Program
ATACAND® (candesartan cilexetil), EMLA® Anesthetic Disc (lidocaine 2.5% and prilocaine 2.5% cream), EMLA® CREAM (lidocaine 2.5% and prilocaine 2.5%), LEXXEL® (enalapril maleate-felodipine ER), PLENDIL® (felodipine), PRILOSEC® (omeprazole), TONOCARD® (tocainide HCl), TOPROL-XL® (metoprolol succinate)
Eligibility
The AstraZeneca Patient Assistance Program is available to qualified patients with a demonstrated medical and financial need, who have exhausted third-party insurance and/or aid from Medicaid and social agencies, and who do not have other means to pay for their medication.
Other Program Information
The physician's office must apply on behalf of a patient. An application is mailed to the physician, or other health care professional with prescribing authority, for his/her signature. Upon receipt and approval of a completed application, a three-month supply of medication will be shipped to the physician's office on the patient's behalf in approximately two weeks.
Name Of Program
FOSCAVIR® Assistance and Information on Reimbursement (F.A.I.R.)
Physician Requests Should Be Directed To
State and Federal Associates
1101 King Street
Alexandria, VA 22314
(800) 488-FAIR (3247)
(703) 683-2239 (fax)
Product(s) Covered By Program
FOSCAVIR® (foscarnet sodium) Injection
Eligibility
If the patient is not covered for outpatient prescription drugs under private insurance or a public program, the patient's income must fall below the level selected by the company. If the patient has insurance coverage for outpatient prescription drugs, he or she may be eligible for assistance with deductibles or maximum benefit limits. Eligibility is determined by the company based on income information provided by the physician.
Other Program Information
Referral must be made by the physician.
Name Of Program
AstraZeneca Foundation Patient Assistance Program
Physician Requests Should Be Directed To
Patient Assistance Program
AstraZeneca Foundation
P.O. Box 15197
Wilmington, DE 19850-5197
(800) 424-3727
Product(s) Covered By Program
ACCOLATE® (zafirlukast) Tablets, ARIMIDEX® (anastrozole) Tablets, CASODEX® (bicalutamide) Tablets, NOLVADEX® (tamoxifen citrate) Tablets, SEROQUEL® (quetiapine fumarate) Tablets, SULAR® (nisoldipine) Tablets, TENORETIC® (atenolol and chlorthalidone) Tablets, TENORMIN® (atenolol) Tablets, ZESTORETIC® (lisinopril and hydrochlorothiazide) Tablets, ZESTRIL® (lisinopril) Tablets, ZOLADEX® (goserelin acetate implant), ZOMIG® (zolmitriptan) Tablets
Eligibility
Patient applications are evaluated on a case-by-case basis by the Zeneca Pharmaceuticals Foundation. Eligibility is based on income level/assets and absence of outpatient private insurance, third-party coverage, or participation in a public program. Income eligibility is based upon multiples of the U.S. poverty level adjusted for household size.
Other Program Information
Reapplication is required every 12 months. A reapplication is automatically sent to enrolled patients. Patient/family members/physician can obtain application forms from the AstraZeneca Foundation by calling 1-800-424-3727. Physicians also can obtain a packet of applications from their AstraZeneca sales representative. Enrollment in the program requires a valid Social Security Number. In addition, the dosage of the medication must conform to FDA approved/labeled indications and dosage regimens.
AVENTIS PASTEUR
Name Of Program
Indigent Patient Program
Physician Requests Should Be Directed To
Customer Account Management
Aventis Pasteur
Discovery Drive
Swiftwater, PA 18370-0187
(800)-VACCINE (800-822-2463)
Product(s) Covered By Program
IMOVAX® Rabies, rabies vaccine; IMOGAM® Rabies-HT, rabies immune globulin (human) (USP); TheraCys® BCG live intravesical (Note: IMOVAX® and IMOGAM® Rabies-HT are provided on a post-exposure basis only)
Eligibility
Determined on a case-by-case basis. Limited to those individuals who have been identified as indigent, uninsured, and ineligible for Medicare and Medicaid; is not eligible for other programs offered by the state, county or city; the patient is a U.S. resident; patient's household income is below federal poverty guidelines. Physician must waive all fees associated with treating the patient and certify product will not be sold, traded, or used for any other purpose but to treat the patient applying for assistance.
Other Program Information
Aventis Pasteur reserves the right to modify or discontinue the Indigent Patient Program at any time for any reason. An application form must be completed, call 1-800-VACCINE to receive an application. Rabies - The physician needs to specify the quantity of IMOGAM® Rabies needed for patient (in mL) as well as the number of doses of IMOVAX® Rabies, along with the patient's age and weight. TheraCys® - Six doses are provided for one induction course of therapy. Connaught does provide, under the program, for a full course of therapy-induction and maintenance-which may be as high as 11 doses (six doses for induction plus as many as fivedoses for maintenance) at the physician's discretion.
AVENTIS PHARMACEUTICALS
Name Of Program
Aventis Pharmaceuticals Patient Assistance Program
Physician Requests Should Be Directed To
Customer Account Management
Aventis Pharmaceuticals Patient Assistance Program
P.O.Box 759
Somerville, NJ 08876
(800)-221-4025
Product(s) Covered By Program
Allegra, Allegra D, Amaryl, Arava, Azmacort, Inhalation Aerosol, Bentyl, Cantil, Carafate, Tablets and Suspension, Claforan, Combipatch, DDAVP Injection, Intranasal and Tablets, Hiprex, Nasacort, AQ Nasal Spray, Nasacort Nasal Spray, Nilandron, Penetrex Tablets, Tilade Inhaler
Eligibility
This program is designed to provide prescription medication, free of charge, to patients who qualify. Aventis will provide product to legal U.S. residents who do no have or qualify for any governmnet or private prescription drug coverage. Additionally, the patient's total annual household income must fall below the Aventis Poverty Level.
Other Program Information
Application forms can be obtained through Aventis and completed by both the physician and patient. A brand name prescription must be attached to every application. Up to a three-month supply of requested product is shipped to the physician's office to be dispensed to approved patients. A new application and prescription is required for reorder. Proof of income is required for initial enrollment and annually thereafter.
Name Of Program
Aventis Oncology Providing Access to Cancer Therapy (PACT) Program
Physician Requests Should Be Directed To
Aventis PACT Program
5870 Trinity Parkway, Suite 600
Centerville, VA 20120
(800) 996-6626
(800) 996-6627 (fax)
ePACT@parexel.com (email)
Product(s) Covered By Program
Anzement, Taxotere
BAYER CORPORATION PHARMACEUTICAL DIVISION
Name Of Program
Bayer Indigent Patient Program
Physician Requests Should Be Directed To
Bayer Indigent Program
P.O. Box 29209
Phoenix, AZ 85038-9209
(800) 468-0894, ext. 2765
Product(s) Covered By Program
Most Bayer pharmaceutical prescription medications used as recommended in prescribing information.
Eligibility
Patient must be a U.S. resident. Physician must certify patient is not eligible for, or covered by, government-funded reimbursement or insurance program for medication; patient is not covered by private insurance; and patient's household income is below federal poverty-level guidelines. Physician must indicate condition for which drug is to be prescribed and certify that drug will be used for indicated use only. Physician must agree to follow patient through therapy. All applications are subject to a case-by-case evaluation by Bayer Corporation.
Other Program Information
Patient/physician can qualify over the phone by calling (800) 998-9180. If all information needed is obtained over the phone, approval or denial is given immediately. If patient is approved, an application is generated and sent to the physician's office for signatures.
BIOGEN, INC.
Name Of Program
Avonex® Access Program SM
Physician Requests Should Be Directed To
MS Active SourceSM
(800) 456-2255
Product(s) Covered By Program
Avonex® (Interferon beta-1a)
Eligibility
Eligibility is based on patient's insurance status and income level.
BOEHRINGER INGELHEIM PHARMACEUTICALS, INC.
Name Of Program
Patient Assistance Program
Physician Requests Should Be Directed To
Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI)
c/o ESI/SDS
P.O. Box 66555
St. Louis, MO 63166-6773
(800) 556-8317 (for information and form)
Product(s) Covered By Program
AGGRENOX®, Atrovent®, CAFCIT®, Catapres-TTS®, COMBIVENT®, FLOMAX®, micardis®, MOBIC®, and VIRAMUNE® for FDA-approved indications only
Eligibility
Eligibility to be determined solely by BIPI. Patient must be a U.S. citizen ineligible for prescription assistance through Medicaid or private insurance. Patient must meet established financial criteria.
Other Program Information
All requests are reviewed and approved on a case-by-case basis. Application form, prescription, and patient's income documentation are required. Maximum of three months supply may be provided per request. Complete financial re-application is required annually. Renewal requests within the same year require only the application form and a prescription.
Program is subject to change without notice. Current program specifics can be obtained by calling the toll-free number above.
BRISTOL-MYERS SQUIBB COMPANY
Name Of Program
Bristol-Myers Squibb Patient Assistance Foundation, Inc.
Physician Requests Should Be Directed To
Bristol-Myers Squibb
Patient Assistance Foundation, Inc.
P.O. Box 4500
Princeton, NJ 08543-4500
Mailcode P25-31
(800) 332-2056; (609) 897-6859 (fax)
Product(s) Covered By Program
Many Bristol-Myers Squibb pharmaceutical products
Eligibility
This program is designed to provide temporary assistance to patients with a financial hardship who are not eligible for prescription drug coverage through Medicaid or any other public or private health program. Patients who meet the program's eligibility criteria are provided BMS products free of charge.
Other Program Information
Physicians and other health care professionals who are interested in enrolling a patient should call the toll-free number above to request an application form.
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