• tmjd.com > resources > patient assistance programs for medications > page 2

Name Of Program
REMICADE^® Patient Assistance Program

Physician Requests Should Be Directed To
REMICADE^® Patient Assistance Program
3060 Ogden Avenue, 3rd Floor
Lisle, IL 60532
(800) 964-8345; (800) 281-7384 (fax)
(8:30 am - 5:00 pm ET, Mon.-Fri.)

Product(s) Covered By Program
REMICADE^® (infliximab, recombinant)

Eligibility
The REMICADE Patient Assistance Program is a service to provide product to low-income patients legally residing in the United States when patients meet certain financial need qualifications. When patients qualify, they may be provided with up to six months of product at a time.

Other Program Information
Health care providers, patients, patients' guardians, and social workers may submit applications for product. All applications will require the signature of the patient or guardian as well as the health care provider. The program only provides product for eligible patients. If the patient meets the eligibility criteria, product is shipped directly to the provider's office or to the site of care.

Name Of Program
Centocor Solutions™ Program for RETAVASE^®

Physician Requests Should Be Directed To
Centocor Solutions Program
1800 Robert Fulton Drive, Suite 300
Reston, VA 20191
(800) 331-5773; (800) 777-7562 (fax)
(9:00 am - 5:00 pm ET, Mon.-Fri.)

Product(s) Covered By Program
RETAVASE^® (reteplase, recombinant)

Eligibility
Centocor Solutions Program will replace RETAVASE used to treat patients who meet specific medical and financial criteria and lack third-party insurance.

Other Program Information
Upon request, an application with a cover letter will be sent to the provider of service to be completed and returned with required documentation. If the patient meets the eligibility requirements, the product will then be shipped directly to the pharmacy of the hospital where the patient was treated.

Please see listings for Novartis Pharmaceuticals.

Name Of Program
DuPont Pharmaceuticals Company Patient Assistance Program

Physician Requests Should Be Directed To
Michelle Paoli
DuPont Pharmaceuticals Company
Chestnut Run Plaza,
Hickory Run Bldg.
974 Centre Road
Wilmington, DE 19805
(800) 474-2762

Product(s) Covered By Program
Most marketed non-controlled prescription products

Eligibility
Eligibility is based on the patient's insurance status and income level/assets. Patients should have exhausted all third-party insurance, Medicaid, Medicare, and all other available programs. The patient must be a resident of the United States.

Other Program Information
The physician should request an application by calling 1-800-474-2762, prompt 5. The physician must complete and sign the physician-designated area of the application and include a signed, completed prescription. The patient must complete and sign the patient-designated area of the application and include a copy of their most current 1040 tax form. The application should be mailed to the address above. It takes approximately two weeks from receipt of an approved application for delivery of medication to the physician.

Name Of Program
Aricept^® (donepezil HCI) Patient Assistance Program

Physician Requests Should Be Directed To
Aricept^® Patient Assistance Program
(800) 226-2072

Product(s) Covered By Program
Aricept^® (donepezil HCI) 5mg and 10 mg tablets

Eligibility
Eisai Inc. and Pfizer Inc have developed the Aricept Patient Assistance Program for those U.S. residents without prescription drug coverage through either public or private insurance. Aricept^® will be provided free of charge to patients who meet the following criteria:

• Patient has no insurance or other third-party payer prescription drug coverage, including Medicaid coverage or Medicare managed care coverage.
• Patient's annual income must fall within a predetermined range.
• Patient must be diagnosed by a physician as having mild to moderate dementia of the Alzheimer's type.

Other Program Information
Patient must requalify after 90-day initial supply.

Name Of Program
Aciphex^® (rabeprazole sodium) Patient Assistance Program

Physician Requests Should Be Directed To
Aciphex^® Patient Assistance Program
(800) 523-5870

Product(s) Covered By Program
Aciphex^® (rabeprazole sodium) 20 mg tablets

Eligibility
Eisai Inc. and JanssenPharmaceutica, Inc. have developed the Aciphex^® Patient Assistance Program for those U.S. residents without prescription drug coverage through either public or private insurance. Aciphex^® will be provided free of charge to patients who meet the following criteria:

Patient has no insurance or other third-party payer prescription drug coverage, including Medicaid coverage or Medicare managed care coverage. Patient's annual income must fall within a predetermined range. Program specialists determine eligibility for each patient. The program requests that physicians not charge patients beyond insurance coverage for professional services. Patient must be diagnosed by a physician as having a medical need for Aciphex®.

Other Program Information
If necessary, patient must requalify after initial supply.

Name Of Program
Elan Pharmaceuticals Prescription Assistance Program

Physician Requests Should Be Directed To
Elan Pharmaceuticals Prescription Assistance Program
c/o Athena Rx Home Pharmacy
800 Gateway Boulevard
South San Francisco, CA 94080
(800) 528-4362 (patients)
(800) 621-4835 (physicians/staff only)

Product(s) Covered By Program
Permax^® (pergolide mesylate), Zanaflex^® (tizanadine hydrochloride), Diastat^® (diazepam rectal gel), Mysoline^® (primidone), Zonegran^® (zonasamide capsules)

Eligibility
The patient must be a resident of the United States, have a net worth less than $30,000 and no third-party prescription drug coverage.

Other Program Information
The prescribing physician and patient must provide the following to Athena Rx Home Pharmacy: a letter of denial from the state Medicaid program; the patient's most recent income tax return, three consecutive bank statements or financial statements from the same account; a letter on the physician's letterhead requesting the medication and assurance on financial need; and a prescription for a one-year supply. Once the request is approved, the product will be shipped quarterly to the patient via UPS delivery. New requests must be filed for additional product.

Name Of Program
Genentech Assistance Program

Physician Requests Should Be Directed To
Genentech, Inc.
P.O. Box 2586
S. San Francisco, CA 94083-2586
(800) 879-4747, (650) 225-1366 (fax)

Product(s) Covered By Program
Activase® (Alteplase), Herceptin® (Trastuzumab), Nutropin® (somatropin), Nutropin AQ® (somatropin), Protropin® (somatrem), Rituxan® (Rituximab) and TNKase™ (Tenecteplase)

Eligibility
For consideration of eligibility for the Genentech Assistance Program, the patient must not be eligible for public or private insurance reimbursement and must meet income restrictions.

Other Program Information

For reimbursement assistance for Nutropin, Nutropin AQ, or Protropin, the physician must contact the Single Point of Contact (SPCO) Reimbursement Department at (800) 545-0488.

For reimbursement assistance for Activase or TNKase, an application must be completed by the treating hospital. For further information and assistance, the hospital may contact the Genentech Reimbursement Hotline at (800) 530-3083.

For reimbursement assistance for Herceptin or Rituxan, an application must be completed and signed by the treating physician. For further information and assistance the physician may contact the Single Point of Contact (SPOC) Reimbursement Department at (800) 249-4918.

Name Of Program
Genentech Endowment for Cystic Fibrosis

Physician Requests Should Be Directed To
Genentech Endowment for Cystic Fibrosis
4828 Parkway Plaza Blvd., Suite 220
Charlotte, NC 28217-1969
(800) 297-5557 (Monday through Friday, 9 a.m. to 5 p.m., ET)
(704) 357-0036 (fax)
www.genentechcfendowment.org (website)

Product(s) Covered By Program
Pulmozyme^® (dornase alfa)

Eligibility
The Endowment offers three programs designed to meet the special needs of the cystic fibrosis (CF) population. If you are uninsured, the Endowment offers an Uninsured Patient Program. You may also be eligible for this program if you have insurance but the policy has certain coverage limitations, such as no drug benefit. If you have insurance, you may qualify for assistance through the Copayment Assistance Program. This program assists qualifying patients with Pulmozyme out-of-pocket copayment requirements based upon a sliding scale adjusted for income, family size, and other pre-established criteria. Both uninsured and underinsured patients may benefit from the Premium Assistance Program. This program assists qualifying patients with insurance premium costs. Assistance levels are based upon a sliding scale.

Other Program Information
Patients may be enrolled in only one program at a time. In addition to the programs described above, the Endowment assists qualifying patients with the purchase of nebulizers and compressors for Pulmozyme administration.

Name Of Program
The BENEFIX Reimbursement and Information Program

Physician Requests Should Be Directed To
(888) 999-2349

Product(s) Covered By Program
Benefix ™ Coagulation Factor IX (recombinant)

Eligibility
The program is designed to provide temporary assistance to patients who meet the pre-determined eligibility criteria. Eligible patients must be without prescription drug coverage from a third-party payer. Patients who meet the eligibility criteria are eligible for a period of 90 days, at which time they must requalify for the program.

Other Program Information
Application forms are sent to physicians who are treating specific patients who may qualify for the program. Application forms must be signed by the patient and physician prior to returning to the program at 1101 King Street, Suite 600, Alexandria, VA 22314.

Name Of Program
Neumega^® Access Program

Physician Requests Should Be Directed To
The Neumega^® Access Program
(888) NEUMEGA (638-6342)

Product(s) Covered By Program
Neumega^® (oprelvekin)

Eligibility
For uninsured and underinsured patients who have limited financial resources.

Other Program Information
Reimbursement specialists provide assistance to physicians, nurses, office managers, pharmacists and patients with insurance reimbursement, such as information on billing and coding. Service staff will also provide individualized help with claims filing and preauthorization requests and provide support in challenging claim denials.

Name Of Program
Ceredase^® / Cerezyme^® Access Program (CAP Program)
Established by the Genzyme Charitable Foundation, Inc.

Physician Requests Should Be Directed To
Wytske Kingma, M.D.
Medical Affairs
Genzyme Corp.
One Kendall Square
Cambridge, MA 01239-1562
(800) 745-4447, ext. 17808

Product(s) Covered By Program
Ceredase^® (alglucerase injection), Cerezyme^® (imiglucerase for injection)

Eligibility
Based on financial and medical need. Must be uninsured and lack the financial means to purchase the drug. In order to maintain eligibility, patients and their families are expected to continue exploring alternative funding options with the Genzyme Case Management Specialist. These options include private insurance, government programs and/or charitable sources.

Other Program Information
The CAP Program is considered a temporary funding program.

Name Of Program
Gilead Sciences Reimbursement Support and Assistance Program

Physician Requests Should Be Directed To
Gilead Sciences Reimbursement Support and Assistance Program
(800) 226-2056; (800) 216-6857 (fax)
(9:00 a.m. to 5:00 p.m. ET)

Product(s) Covered By Program
Daunoxome® (daunorubicin citrate liposome injection), Vistide® (cidofovir injection)

Eligibility
Gilead Sciences Reimbursement Support and Assistance Program is designed to assist both insured and uninsured patients in receiving reimbursement for VISTIDE or DAUNOXOME. To determine eligibility for this program, physicians or patients may request a Patient Assistance Program application for VISTIDE or DAUNOXOME and mail or fax the completed form to Gilead Sciences Reimbursement Support and Assistance Program.

Other Program Information
The program offers insurance claims assistance, referrals for financial support, referrals to AIDS service agencies. Support specialists consult with insured patients and their physicians regarding prior authorization or third-party insurance claims, contact insurance companies on behalf of patients and contact patients and physicians to offer appeal procedures.

Name Of Program
Glaxo Wellcome Patient Assistance Program

Physician Requests Should Be Directed To
Glaxo Wellcome Inc.
Patient Assistance Program
P.O. Box 52185
Phoenix, AZ 85072-2185
(800) 722-9294
(800) 750-9832 (fax)

Additional Program Information Can Be Found At:
www.glaxowellcome.com/pap
Program materials may also be ordered by health professionals through this website.

Product(s) Covered By Program
All marketed Glaxo Wellcome prescription products used in an outpatient setting.

Eligibility
The Glaxo Wellcome Patient Assistance Program has been established to provide short-term assistance to eligible patients until alternative funding can be found. All Glaxo Wellcome medications used in an outpatient setting are available. The Glaxo Wellcome Patient Assistance Program is a philanthropic activity of Glaxo Wellcome. The Program is intended to serve patients who do not have drug benefits through private insurance or government-funded programs. The Patient Assistance Program is not intended to replace government programs.

Other Program Information
The Glaxo Wellcome Patient Assistance Program not only provides medications but also provides reimbursement services to help patients locate other payment sources that may provide more comprehensive health care coverage.

Health care advocates should fill out the application form and call 1-800-722-9294 to enroll patients. Completed applications are reviewed against the company's established criteria on a case-by-case basis. Income eligibility is based upon multiples of the federal poverty level adjusted for household size. The only fee that patients are required to pay to participate in the program is a nominal pharmacy copayment. Program benefits for outpatient products are provided through pharmacies. Injectable products are provided to the health care provider via direct product shipment.

Name Of Program
SmithKline Beecham Foundation Access to Care

Physician Requests Should Be Directed To
SmithKline Beecham Foundation Access to Care
c/o Express Scripts/SDS
P.O. Box 2564
Maryland Heights, MO 63043-8564
(800) 546-0420
(800) 729-4544

Product(s) Covered By Program
Amoxil, Augmentin, Avandia, Bactroban, Compazine, Coreg, Dyazide, Famvir, Paxil, Relafen, Requip and Tagamet. Hycamtin is covered under a separate Access to Care program. (See next listing.)

Eligibility
The patient has a medical condition for which the medication is needed. The patient has represented that his/her annual household income is under $25,000. The cost of the patient's prescription is not fully covered by medical insurance, government aid (e.g., Medicare) or private programs, and in the opinion of the treating physician, the cost of this therapy may impose significant hardship on the patient or result in noncompliance with treatment.

Other Program Information
Application forms can be obtained by calling 1-800-546-0420. The patient and the physician fill out the application and should be sure to include all information. Incomplete forms will be returned. Both patient and physician must sign the form. The physician indicates the strength and dosage of the requested product on the prescription. A separate form and prescription must be sent for each individual. All requests must be submitted on an original SB Foundation Access to Care form. Photocopies of the application will not be accepted under any circumstances. Reapplications are required. The product will be sent to the patient's home and will require a signature upon delivery. Third-party requests will not be honored.

The SmithKline Beecham Foundation reserves the right to eliminate or modify the use of its Access to Care certificates and make such changes at any time without notice.

Name Of Program
Oncology Access to Care Program

Physician Requests Should Be Directed To
The Oncology Access to Care Hotline
(800) 699-3806

Product(s) Covered By Program
Hycamtin (topotecan HCl)

Please see listing for Aventis Pharmaceuticals.

Name Of Program
Immunex Patient Assistance Program

Physician Requests Should Be Directed To
Immunex Patient Assistance Program
(800) 321-4669; (800) 944-3184 (fax)

Product(s) Covered By Program
LEUKINE® (sagramostim), NOVANTRONE® (mitoxantrone for injection concentrate), Leucovorin Calcium tablets, Leucovorin Calcium for injection, Methotrexate sodium injection, AMICAR® (aminocaproic acid), THIOPLEX® (thiotepa for injection)

Eligibility
Eligibility is based on criteria that include the patient's insurance status and income level. Patients must be ineligible for any other third-party reimbursement or support program to apply for the Immunex Patient Assistance Program. Eligibility criteria are subject to change without notice.

Other Program Information
The physician applies on behalf of the patient. All requests are reviewed and approved on a case-by-case basis. Application form, prescription, and patient's income documentation are required. Once eligibility has been verified, up to a three-month supply of the prescribed medication(s) is sent directly to the the prescriber's office for distribution to the patient.

Program is subject to change without notice. Current program specifics can be obtained by calling 1-800-321-4669.

Name Of Program
Janssen Patient Assistance Program

Physician Requests Should Be Directed To
Janssen Patient Assistance Program
1800 Robert Fulton Drive
Reston, VA 20191-4346
(800) 652-6227

Product(s) Covered By Program
Janssen's medical prescription products

Eligibility
Program will ensure that Janssen's prescription products [Duragesic® (fentanyl transdermal), Nizoral® Tablet (ketaconazole tablet), Sporanox® (itraconazole)] will be free of charge to any persons who meet specific medical criteria and lack financial resources and third-party insurance necessary to obtain treatment. Program specialist determines eligibility for each patient. Janssen requests that physicians not charge patients beyond insurance coverage for professional services.

Other Program Information
One or two months' supply available; varies by product.

Name Of Program
Aciphex® Patient Assistance Program (Please see listing for Eisai Inc. for complete program information.)

Name Of Program
The Risperdal Patient Assistance Program and The Risperdal Reimbursement Support Program

Physician Requests Should Be Directed To
Janssen Cares
The Risperdal Patient Assistance Program
P.O. Box 222098
Charlotte, NC 28222-2098
(800) 652-6227, Monday through Friday
(9:00 a.m. to 5:00 p.m. E.T.)
(704) 357-0036 (fax)

Eligibility
Program will ensure that all RISPERDAL® (risperidone) is made available free of charge to any persons who lack financial resources and third-party insurance necessary to obtain treatment. Reimbursement specialist determines eligibility for each patient. Janssen requests that physicians not charge patients beyond insurance coverage for professional services.

The Risperdal Reimbursement Support Program is designed to answer physicians' and patients' questions and solve problems related to Risperdal reimbursement as efficiently and quickly as possible.