Patient Assistance Programs

1. 3M Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	3M Pharmaceuticals
Program Name	3M Pharmaceuticals Patient Assistance Program
Program Address	3M Center Bldg. 275-6W-13 St. Paul, MN 55144
Medicines On Program	Aldara cream, Maxair Autohaler, Metrogel-Vaginal .075%, Vaginal Use, Minitran transdermal delivery system, Norflex tablets, Norgesic Forte, Norgesic tablets, Tambocor
Phone Number	800-328-0255, opt 1
Guidelines and Notes	Patient must have no prescription coverage for any medications, be ineligible for any state or federal assistance, and not be able to buy the medication. Physician should only refer patient’s whose income, in their judgement, is so low that purchasing the medication is causing unreasonable hardship. Patient’s income should be below 200% of the Federal Poverty Level.
Initiating Enrollment	Physician’s office or social worker must call for Authorization Form with: prescriber’s name, phone, degree, address, patient’s name and medication /strength needed. The Authorization Form is patient specific and can’t be copied, the form is faxed to the doctor’s office. The completed form can be faxed or mailed back.
Health Provider’s Role	The physician fills out a section, gives state license number and signs the form.
Patient’s Role	Patient provides income, household size, insurance, medical and prescription expense information and sign the form.
How Dispensed	Sends medicine to physician or to a specified pharmacist at a hospital or health care entity.
Amount Dispensed	Varies according to product — Aldara: 4 box of 12 packets; Maxair Autohaler: 3 inhalers; MetroGel Vaginal Cream: one 70 gm tube; Minitran: 120 patches (4 mos. supply); All tablets: 300 tablets.
Refills	The patient can call for refills. Every three months a new application is needed.
Limit	Indefinitely

2. AAI Pharma Inc

Pharmaceutical Company	AAI Pharma Inc.
Program Name	AAI Pharma Assists
Program Address	PO Box 124 Somerville, NJ 08876
Medicines On Program	AquaSol A , AquaSol E Drops, Azasan, Brethine Solution for Injection, Brethine Tablets, Darvocet A500, Darvocet-N 50, Darvon Compound-32, Darvon Compound-65, Darvon-N, 100mg, M.V.I Pediatric, M.V.I-12
Phone Number	866.224.0099
Guidelines and Notes	The patient must be a US resident with no private or public prescription coverage. The patient must also be at or below 120% of the Federal Poverty Guideline and a US resident.
Initiating Enrollment	Anyone can call for an application and it will be automatically faxed out. The blank application can be copied. The completed application must be mailed back.
Health Provider’s Role	The doctor must fill in a section and sign the application.
Patient’s Role	The patient must fill in a section, sign the application and attach proof of income.
How Dispensed	The patient is sent a pharmacy card that must be taken to the pharmacy. The patient must pay a $10 co-pay for each prescription filled.
Amount Dispensed	The prescription can be written for up to a 3 month supply at a time.
Refills	After six months an re-order application is required to continue card activation. Once a year a new application with documentation is needed. The same applicaition is used for initail enrollment, annual enrollment and for Re-Orders.
Limit	Indefinitely

3. Abbott Laboratories Patient Assistance Program

Pharmaceutical Company	Abbott Laboratories
Program Name	Abbott Laboratories Patient Assistance Program
Program Address	Pharaceutical Products Div. Dept D-31C, J23 200 Abbott Park Rd. Abbott Park, IL 60064
Medicines On Program	Biaxin, Calijex, Colchicine, Cylert, Depakene, Depakote ER Tabs, Depakote Tablets, Fero-Folic 500, Gengraf, Hytrin, Iberet Folic 500, Isoptin SR, K-Lor, K-Tab, Kaletra Oral Solution, Kaletra Tablets, Mavik, Norvir Oral Solution, Norvir Soft Gelatin, Omnicef, Synthroid, Tarka, Tricor, Zemplar
Phone Number	800-222-6885
Guidelines and Notes	Call 8.00am – 5.00pm CST. Patient’s must be under the current Federal Poverty Guidellines, have no third party prescription coverage or state or federal help. NOTE: The list of medications is unclear because a medication may not be noted as on the program but is handled case by case. Have a doctor call in for a medication if it is not on the list. On the same note: some medications on the list are special case only.
Initiating Enrollment	Licensed prescriber or nurse must call for the application. Application can be copied. Completed application may be faxed with documentation.
Health Provider’s Role	Doctor completes and signs, cannot be a stamped signature. No prescription needed.
Patient’s Role	The patient needs to fill out a section, sign and attach proof of income for all members of the household.
How Dispensed	Sends medicine to doctor’s office in about 2 weeks.
Amount Dispensed	3 month supply.
Refills	The doctor’s office needs to call for refills about a month before medication runs out. If more medication is needed after the eligibility period has ended a re-enrollement application will be sent to the doctor’s office. After a year, patient must completely reapply.
Limit	Indefinite

4. Abbott Virology Patient Assistance Program

Pharmaceutical Company	Abbott Laboratories
Program Name	Abbott Virology Patient Assistance Program
Program Address	D-31C, J23 200 Abbott Park Road Abbott Park, IL 60064-6161
Medicines On Program	Kaletra, Norvir
Phone Number	800-222-6885, opt #2
Guidelines and Notes	The patient cannot have insurance that covers the medication, and not be eligible for any public assistance. For Kaletra, the patient must also meet financial guidelines that are not disclosed
Initiating Enrollment	Someone from the doctor’s office must call for an application. The blank application can be copied. The completed application can be faxed or mailed back.
Health Provider’s Role	The doctor must fill out a section of the application and sign.
Patient’s Role	The patient must fill out a section of the application and sign.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The medication is sent in a 3 month supply.
Refills	The doctor’s office must call for refills 3 weeks before the current supply runs out. After a year a new application is needed.
Limit	Indefinitely

5. Access for Humatrope

Pharmaceutical Company
Program Name	Access for Humatrope
Program Address	Humatrope Reimbursement Center 100 Grandview Rd., Suite 210 Braintree MA 02184
Medicines On Program	Humatrope 5mg vial, HumatroPen Injection Device 12mg Cart., HumatroPen Injection Device 24mg Cart., HumatroPen Injection Device 6mg Cart.
Phone Number	800-642-2340
Guidelines and Notes	The program acts as an advocate for the patient and tries to uncover another source for payment. If that fails, the program provides the drug free of charge or with a co-pay, as determined by consideration of patient/household income information. This is a last resort. The program is based on guidelines which are not released.
Initiating Enrollment	Anyone can call for an application, but they prefer a doctor’s office to call. Or it can be downloaded from www.humatrope.com. The completed application can be faxed back.
Health Provider’s Role	The physician fills outs sections of the application including diagnosis, device and authorization. The phyisican must also sign the application.
Patient’s Role	The patient must provide basic information and provide insurance information. The patient must also provide the most recent 10-40.
How Dispensed	Either makes arrangement for a home care provider to receive and administor, or sends drug to referring endocrinologist.
Amount Dispensed	The medication is sent out in three month supply.
Refills	Depending on who ships the medication, the refill procedure is different. Most will call the patient to get information for refills. Every nine months the case is reopened and the company contacts the patient for renewel.
Limit	Indefinitely

6. Aciphex Patient Assistance Program

Pharmaceutical Company	Janssen & Eisai, Inc
Program Name	Aciphex Patient Assistance Program
Program Address	PO Box 220458 Charlotte, NC 28222-0458
Medicines On Program	Aciphex
Phone Number	800-523-5870
Guidelines and Notes	Program is a joint venture between Eisai and Janssen Pharmaceuticals. Each case is dealt with on an individual basis- all benefits are verified for any insurance. Patients can have some insurance, there is no hard rules about coverage. The patient must also fall under financial guidelines that are not disclosed. Call between 9-5 Eastern Time weekdays.
Initiating Enrollment	Anyone can call for an application, and it will be faxed out. The blank application can be photocopied. The completed application can be faxed back to the company.
Health Provider’s Role	The physician completes a section, signs it and notes whether this is re-application or a new application.
Patient’s Role	The patient must also fill out a section and sign it. The patient must also attach proof of income.
How Dispensed	The medication is sent to the physician’s office.
Amount Dispensed	The medication is sent in a 30 day supply of 20 mg tablets.
Refills	the company will automatically will ship for six months as long as the prescription has the refills. Patient must reapply every 6 months.
Limit	Indefinitely

7. Acthar Gel Patient Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Acthar Gel Patient Assistance Program
Program Address	C/O NORD PO Box 1968 New Fairfield, CT 06812-1968
Medicines On Program	Acthar Gel
Phone Number	1-800-459-7599
Guidelines and Notes	Eligibility is based on income and lack of prescription coverage. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assistance up from 25%-100% for one year.
Initiating Enrollment	Anyone can call to start the process an application can be mailed to patient, doctor or social worker. The completed application can be faxed back to NORD.
Health Provider’s Role	The doctor completes a section, signs and attaches a prescription to the application.
Patient’s Role	Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the form.
How Dispensed	The medication is sent either to the doctor’s office or a pharmacy.
Amount Dispensed	Depends on amount awarded to patient.
Refills	A new application is needed once a year.
Limit	Indefinitely

8. Actimune & Infergen Patient Assistance Program

Pharmaceutical Company	InterMune Pharmaceuticals
Program Name	Actimune & Infergen Patient Assistance Program
Program Address	PO Box 4280 Gaithersburg, MD 20885
Medicines On Program	Actimmune
Phone Number	800-577-9112
Guidelines and Notes	Patients must have either Chronic Granulomatous Disease or Osteopetrosis Disease. The patient must meet certain financial guidelines which are not disclosed.
Initiating Enrollment	They no longer send out applications. Anyone can call for a pre-screening, then a patient specific application is sent to the doctor’s office.
Health Provider’s Role	Doctor provides proof of diagnosis of chronic granulomatous disease and can write a prescription for up to a year. The doctor must also sign the application and attach a copy of the state license.
Patient’s Role	Patient must fill out a section of the application, sign and attach proof of income.
How Dispensed	Sends medicine to the doctor’s office or the pharmacy.
Amount Dispensed	3 months supply at a time.
Refills	The doctor’s office must call the company two weeks prior to running out of medication, and a new shipment will be sent out. Once a year a new application is needed.
Limit	Indefinite

9. Aggrastat Patient Assistance Program

Pharmaceutical Company	Merck & Company , Inc.
Program Name	Aggrastat Patient Assistance Program
Program Address	PO Box 222137 Charlotte, NC 28222-2137
Medicines On Program	Aggrastat
Phone Number	877-810-0595
Guidelines and Notes	It’s a product replacement program, a hospital social worker usually applies after an uninsured patient is treated with the drug. The patients who are completely uninsured and meet financial guidelines.
Initiating Enrollment	Hospital calls to get application. The blank application can be copied. The completed application is faxed back to the company.
Health Provider’s Role	Put doctor’s name on application; authorized hospital representative signs it. (usually social worker). Pharmacy dispensing record and drug invoice must be sent in with application.The NDC number must appear on the invoice.
Patient’s Role	Patient’s name, Social Secuirty Number, address and date of birth is needed. Financial documents must be provided on behalf of the patient.
How Dispensed	Sent to hospital or facility to reimburse them for product used.
Amount Dispensed	Full trays of medication are sent only.
Refills	n/a
Limit	Indefinitely

10. Agouron Patient Assistance Program

Pharmaceutical Company	Agouron Pharmaceuticals, Inc.
Program Name	Agouron Patient Assistance Program
Program Address	PO Box 230536 Centerville, VA 20120
Medicines On Program	Rescriptor, Viracept
Phone Number	888-777-6637
Guidelines and Notes	Patients must met in-house guidelines that they do not disclose. Patients must also apply to ADAP in order to apply for this program. If a patient is accepted into ADAP then the company will discontinue their assistance, usually after a month. The only times their will accept a fax of the application is in extreme cases such as rape. Other than that the application must be mailed in.
Initiating Enrollment	Anyone can call to start the process with the patient’s permission. All that is needed is the doctor’s name, address, DEA number, phone number and the patient’s phone number and name. The company then mails a patient specific application to the doctor’s office.
Health Provider’s Role	The doctor must fill out section 1 of the application. A prescription for a four month supply must also be attached.
Patient’s Role	Patient must fill out section 2 of the application and include TWO pieces of documentation of their proof of income. The patient must also show proof that they have applied to ADAP as well.
How Dispensed	Medication is sent to the doctor’s office, within 2-3 days.
Amount Dispensed	Medication is sent out in one month supply.
Refills	After 18-21 days a new shippment is automatically sent out. Every three months a new application and new prescription is needed. Finanical documents are only needed once a year.
Limit	Indefinite

11. Alcon Cares Patient Assistance Program

Pharmaceutical Company	Alcon Labs
Program Name	Alcon Cares Patient Assistance Program
Program Address	Not Applicable
Medicines On Program	Azopt 1% (15 ml btl), Betoptic S 0.25% (15 ml btl), Bion Tears, Brimonidine Tartate 0.2% (15ml btl), Carteolol HCL 1% (10 ml btl), Ciloxan Ointment (3.5 g tube), Ciloxan Solution (5 ml btl), Cipro HC Otic (10 ml btl), Ciprodex (7.5 ml btl), Dipivefrin HCL 1% (15 ml btl), Econopred Plus (10 ml btl), Flarex (5 ml btl), Iopidine 0.5% (10 ml btl), Isopto Carbachol 1.5% (30ml btl), Isopto Carbachol 3% (30 ml btl), Isopto Carpine 1% (15 ml btl), Isopto Carpine 2% (15 ml btl), Isopto Carpine 4% (15 ml btl), Levolbunolol HCL .5% (10 ml btl), Maxitrol Suspension (5 ml btl), Metipranolol Solution 0.3% (10 ml btl), Pilopine HS 4% Gel (4 g tube), Systane, Tears Naturale Forte, Tears Naturale Free Lubricant Eye Drops, Tears Naturale PM Ointment, Timolol Malcate Gel 0 .5% (5 ml btl), Timolol Maleate Gel 0.25% (5 ml btl), Timolol Maleate Solution 0.25% (15 ml btl), Timolol Maleate Solution 0.5% (15 ml btl), TobraDex Ophthalmic Ointment (3.5 g tube), TobraDex Suspension (10 ml btl), Travatan 0.004% (2.5 ml btl), Unisol 4 Saline, Vexol (10 ml btl), Vigamox (3ml btl)
Phone Number	800-222-8103, opt 2
Guidelines and Notes	This program is open to patients being treated by a US licensed physician who feels the patient cannot afford the medication. The patient also must have no prescription insurance coverage and does not qualify for any public perscription programs. The patient’s annual income must be at or below $18,000 for single person, $25,000 for a family of 2 and $36,000 for a family of 4.
Initiating Enrollment	The doctor can call for the application and it will be sent out. The blank application can be copied. The completed application can be faxed back.
Health Provider’s Role	The doctor must fill out a section of the application and sign it.
Patient’s Role	The patient must sign the application.
How Dispensed	Prescription medications are sent to the doctor’s office, but over the counter medications can be sent to the patient’s house.
Amount Dispensed	Over-the-counter medications and Glaucoma medications are sent in a 6 month supply. The amount of the perscription medicine sent depends on the need.
Refills	To get another supply another application is needed. For over-the-counter medicines the limit is one 6 month supply a year.
Limit	Indefinitely.

12. Allergan Patient Assistance Program

Pharmaceutical Company	Allergan, Inc.
Program Name	Allergan Patient Assistance Program
Program Address	PO Box 1003 Wayne NJ, O7474-9928
Medicines On Program	Alphagan P 0.15% 10 ml, Betagan .25% B.I.D. ,15ml, Betagan .5% B.I.D. ,15ml, Celluvisc, Lumigan .03% Q.D., 7.5 ml, Refresh Liquigel, Refresh Plus, Refresh PM, Refresh Tears, Restasis .05%, 32x.4ml, Tazorac Cream 0.05%, Tazorac Cream 0.1%, Tazorac Gel 0.05%, Tazorac Gel 0.1%
Phone Number	800-553-6783
Guidelines and Notes	The patient must have no prescription coverage, and make less that $12,000 for a one or two person family, or less than $19,000 for a 3 or more family. There is a limit of 2 Over the Counter medications and 2 prescription medications per 6 months per patient.
Initiating Enrollment	Anyone can call for the application or get it off the website. The completed application must be mailed back.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient fills out a section on the application and signs it as well.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A six month supply is sent to the office, to be given to the patient in whatever dosage seems fit.
Refills	The last week of the 5th month, a new application should be mailed to the company.
Limit	Unspecified

13. Amgen Safety Net Foundation for Kineret

Pharmaceutical Company	Amgen, Inc.
Program Name	Amgen Safety Net Foundation for Kineret
Program Address	c/o InTeleCenter, 9th Floor PO Box 4280 Gaithersburg, MD 20897
Medicines On Program	Kineret
Phone Number	1-866-546-3738
Guidelines and Notes	The patient must be US resident, can not have insurance that covers prescriptions, doesn’t cover injectables, or the insurance has reached a cap. The patient may have Medicaid with a spend down that they are unable to met. The company will also send out one free SimpleJect Device to aid patients in the injection, if needed.
Initiating Enrollment	Anyone can call for an application, it will faxed out. The blank application can be copied. A completed application can be faxed back.
Health Provider’s Role	The physician must fill one page of the application, and sign it. The physician must attach a prescription made out for one year. If the patient needs the SimpleJect Device, a second prescription must be written.
Patient’s Role	Must fill out 2 pages of the application, including information about annual gross income, sources of income and sign the application in two places.
How Dispensed	The medication will be sent to the doctor’s office or the patient’s house. But someone must sign for the medication.
Amount Dispensed	The medication will be sent out in 2 month supplies.
Refills	The medication will be automatically sent out until the end of the year, when a whole new application. The company will send out a renewal application about 1 month before the year ends.
Limit	Not Applicable

14. Arch Foundation Patient Assitance Program for Mirena

Pharmaceutical Company	Arch Foundation
Program Name	Arch Foundation Patient Assitance Program for Mirena
Program Address	P.O. Box 220908 Charlotte NC, 28222-0908
Medicines On Program	Mirena
Phone Number	877.393.9071
Guidelines and Notes	This is a program for patients who have no insurance for birth control (Mirena is an IUD). The patient must be a US resident who is being treated by a US licensed health care provider. The company does have financial guidelines but they are not disclosed. While the company will pay for the IUD, it does not pay for inseration services or removal services.
Initiating Enrollment	Anyone can call for an application The blank application can be copied. The completed application can be mailed or faxed back to the company
Health Provider’s Role	The health care provider must fill out a section and sign the application. The doctor who will be inserting the device must also sign the application.
Patient’s Role	The patient must fill out a section about insurance and financial information and sign the application.
How Dispensed	The Mirana is sent to the clinic to be placed, it is sent in 3-5 buisness days.
Amount Dispensed	Not Applicable
Refills	Not Applicable
Limit	Not Applicable

15. Aricept Assistance Program

Pharmaceutical Company	Pfizer, Inc.& Eisai
Program Name	Aricept 10 mg Tablets, Aricept 5 mg Tablets
Program Address	1480 Arthur Ave, Ste D Louisville, CO 80027
Medicines On Program	Aricept 10 mg Tablets, Aricept 5 mg Tablets
Phone Number	800-226-2072
Guidelines and Notes	Patient must be a US resident and meet financial guidelines that are not disclosed. The patient must also be getting care on an out patient basis only
Initiating Enrollment	It is preferred that the doctor call for the qualifying application or re-qualifying application, which will be faxed out. The blank applications can be photocopied. The completed application can be faxed or mailed back.
Health Provider’s Role	Doctor completes a section and signs it. Prescription is incorporated into the application.
Patient’s Role	Patient or power of attorney must sign the application.
How Dispensed	Medicine is sent to doctor’s office.
Amount Dispensed	3 month supply.
Refills	The doctor calls to request Requalification Form when patient starts the last 30 tablets. After a year a whole new application is needed.
Limit	Indefinite

16. Arixtra Reimbursement Services

Pharmaceutical Company	Sanofi-Synthelabo Pharmaceuticals, Inc.
Program Name	Arixtra Reimbursement Services
Program Address	Not Applicable
Medicines On Program	Arixtra
Phone Number	866-274-9872, opt 5
Guidelines and Notes	The patient cannot have any prescription coverage for the medication and must meet financial guidelines that are not disclosed.
Initiating Enrollment	Anyone can call for application and it will be faxed out. The blank application can be copied.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section and sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	One dosage, usually a week, is sent out.
Refills	This is usually a one time medication, but if more medication is needed then a new application is required.
Limit	See Above.

17. Astra Zeneca Foundation Patient Assistance Program

Pharmaceutical Company	Astra Zeneca Pharmaceuticals
Program Name	Astra Zeneca Foundation Patient Assistance Program
Program Address	PO Box 66551 St. Louis, MO 63166-6551
Medicines On Program	Accolate Tablets 10 mg, Accolate Tablets 20 mg, Atacand HCT Tablets 16/12.5mg, Atacand HCT Tablets 32/12.5mg, Atacand Tablets 16 mg, Atacand Tablets 32 mg, Atacand Tablets 8 mg, Crestor Tablets 10mg, Crestor Tablets 20mg, Crestor Tablets 40mg, Crestor Tablets 5mg, Emla Cream 5% tube, Entocort EC Capsules 3 mg, Nexium DR Capsules 20 mg, Nexium DR Capsules 40 mg, Plendil Tablets 2.5 mg, Plendil Tablets 10 mg, Plendil Tablets 5 mg, Pulmicort Respules .25mg/2mL, Pulmicort Respules 0.5mg/2mL, Pulmicort Turboinhaler 200 mcg, Rhinocort Aqua Nasal Spray 32 mcg, Seroquel Tablets 200 mg, Seroquel Tablets 25 mg, Seroquel Tablets 300 mg, Toprol XL Tablets 100 mg, Toprol XL Tablets 200 mg, Toprol XL Tablets 50 mg, Zoladex 10.8 mg Depot every 3 months, Zoladex 3.6 mg Depot monthly
Phone Number	800-424-3727
Guidelines and Notes	Patients must be US citizens with a valid Social Secruity number and have an annual income below $18,000 per individual or $24,000 for couples. For information about status of mailed prescription call 800-698-0085. They are often backlogged and ask that someone calls to check the patient’s status before sending in an application or reapplication. For Oncology medications, see Astra Zeneca Foundation Patient Assistance Program for Oncology.
Initiating Enrollment	The application can be downloaded from their website (http://www.astrazeneca-us.com/pap/) or call the above number Completed application should be mailed back to the company.
Health Provider’s Role	Doctor completes and signs a section of the application. A prescription must be attached or fill out the prescription information on the appilcation.
Patient’s Role	The patient must fill out the patient section and sign it. They must also attach proof of income and either a denial letter from Medicaid or a copy of the Medicaid card.
How Dispensed	The medication can be sent to either the patient or the doctor.
Amount Dispensed	A three month supply.
Refills	20 to 30 days before the medication runs out, the patient must call the number on the medication bottle for a refill. Totally new applications needed once a year. A re-application is sent 45 days prior to one year expiration date.
Limit	Indefinitely

18. Astra Zeneca Foundation Patient Assistance Program for Oncology

Pharmaceutical Company	Astra Zeneca Pharmaceuticals
Program Name	Astra Zeneca Foundation Patient Assistance Program for Oncology
Program Address	PO Box 66551 St. Louis, MO 63166-6551
Medicines On Program	Arimidex Tablets, 1 mg, Casodex Tablets 50 mg, Faslodex 2.5 mL (1 month injection), Faslodex 5 mL (1 month injection), Nolvadex Tablets 10 mg
Fax Number	Not Applicable
Guidelines and Notes	This phone number is for the Cancer Support Network through Astra Zeneca. This program is the same as the Astra Zeneca Foundation Patient Assistance Program except the process is much faster for the oncology medications. This program also tries to find funding for the patient before using the patient assistance component.
Initiating Enrollment	Anyone can call for an application and they will fax it out. The blank application is the same as the application for the Astra Zeneca Foundation but call the above number to get fax numbers to rush the process.
Health Provider’s Role	Doctor completes and signs a section of the application. A prescription must be attached or fill out the prescription information on the appilcation.
Patient’s Role	The patient must fill out the patient section and sign it. They must also attach proof of income and either a denial letter from Medicaid or a copy of the Medicaid card.
How Dispensed	The medication can be sent to either the patient or the doctor.
Amount Dispensed	A three month supply.
Refills	20 to 30 days before the medication runs out, the patient must call the number on the medication bottle for a refill. Totally new application needed once a year. A re-application is sent 45 days prior to one year expiration date.
Limit	Indefinitely.

19. Aventis Behring Patient Assistance Program

Pharmaceutical Company	Aventis Behring
Program Name	Aventis Behring Patient Assistance Program
Program Address	1020 First Ave. King of Prussia, PA 19406
Medicines On Program	Gammar-PIV, Helixate 8FS, Humate-P, Monoclate-P, MonoNine, Stimate, Zemaira
Phone Number	800-676-4266
Application	Contact program for application
Guidelines and Notes	This program has some specific guildelines that are not disclosed. Since drugs availability changes based on inventory, call if drug needed is not on list. The list is also subject to change.
Initiating Enrollment	Anyone can call to start the process, they take information over the phone and send a patient-specific application. The completed application must be mailed back.
Health Provider’s Role	The provider must complete a section of applicaiton and attach an original prescription. Information needed includes history of treatment. Provider will also have to make a case for why patient needs assistance.
Patient’s Role	The patient must provide basic financial, and insurance information and sign a section of the application.

How Dispensed	The medication will be sent to a licensed site.
Amount Dispensed	Usually the medication is sent out in a 3 month supply.
Refills	Every three months the patient must be reevaluated, and a new application is needed.
Limit	not specified

20. Aventis Oncology Pact+ Program

Pharmaceutical Company	Aventis Pharmaceuticals
Program Name	Aventis Oncology Pact+ Program
Program Address	100 Grandview Rd. Ste 210 Braintree MA, 02184
Medicines On Program	Anzemet CINV injections, Anzemet CINV Tablets, Anzemet PONV injection, Anzemet PONV Tablets, Nilandron Tablets, Taxotere
Phone Number	800-996-6626 #1
Guidelines and Notes	For each drug there is a different application.(In NeedyMeds there are all together.) Patients who have no insurance, who are underinsured or have already received their maximum benefits may be eligible for alternative funding are eligible. Nilandron Tablets require patients to be below the Aventis Poverty Level (family of one below $17,960 per year, for family of 2 below $24,240 more details on application.)
Initiating Enrollment	If a patient or doctor calls for application, they will take information make it patient specific, so have patient’s chart ready. Blank applications are also available on www.aventisoncology.com. These applications can be copied. Completed applications can be faxed back except for Nilandron, which must be mailed back. The company will call to follow up on additional information and send out a patient consent form.
Health Provider’s Role	The doctor must fill out a section including a signature and a DEA number. For Nilandron, the doctor must also send a prescription for upto a three month supply.
Patient’s Role	The patient must provide medical, insurance and annual household income. For Nilandron, patient must also attach proof of income.
How Dispensed	Medication is sent to the doctor’s office.
Amount Dispensed	Three cycles of treatment are supplied. The actual amount different depending on the medication.
Refills	Doctor complete a re-order form with is included with initial approval letter. Re-order is faxed and processed based on the product’s treatment cycle. If the perscription has changed a new reorder must be completed. Once a year a new application is needed.
Limit	Indefinitely

21. Aventis Patient Assistance Program

Pharmaceutical Company	Aventis Pharmaceuticals
Program Name	Aventis Patient Assistance Program
Program Address	PO Box 759 Somerville, NJ 08876
Medicines On Program	Allegra 180 mg Tablets, Allegra 30 mg Tablets, Allegra 60mg Tablets, Allegra D 60 mg Tablets, Amaryl 1 mg Tablets, Allegra 180 mg Tablets, Allegra 30 mg Tablets, Allegra 60mg Tablets, Allegra D 60 mg Tablets, Amaryl 1 mg Tablets,
Phone Number	800-221-4025
Guidelines and Notes	Patients must be US residents who don’t qualify for any government or private insurance for prescriptions. The patient’s total annual income must be at or below 200% of the current Federal Poverty Guidelines.
Initiating Enrollment	Anyone can call for a form, it will be faxed out. The application can be copied. The completed application must be mailed back to the company.
Health Provider’s Role	Doctor completes, signs, and attaches a prescription for up to a 90 day supply (except Lantus which is provided in minimum of 4 vial supply for 6 month supply and in increments of 10).
Patient’s Role	The patient must fill out a section, sign and attach a copy of federal tax income tax return. If no taxes were filed, some form of proof of income is required.
How Dispensed	Medication is sent to the doctor’s office. The patient’s name will be on the mailing label, not the bottle.
Amount Dispensed	Varies by medication. Usually a three month supply. Takes 4 weeks for them to process and send the medication.
Refills	Use an entirely new application, just like first time with a perscription, but proof of income is only needed once a year.
Limit	Unspecified

22. Axcan Assist Program

Pharmaceutical Company	Axcan-Scandipharm, Inc
Program Name	Axcan Assist Program
Program Address	PO Box 52065 Phoenix AZ, 85072-9152
Medicines On Program	Bentyl 10mg Tablets, Bentyl 20mg Tablets, Carafate Oral Suspension, Carafate Tablets 1 gm, Urso 250, Viokase 16 Powder, Viokase 16 Tablet
Phone Number	866-292-2679, opt 2
Guidelines and Notes	The patient must be at or below the Federal Poverty Guidelines, with no perscription coverage. If the patient has coverage but has capped it, then they are still eligible but have a co-pay of$3 to $18.
Initiating Enrollment	Anyone can call to start the process. The person must have the patient’s Social Secruity Number, insurance information, gross monthy income, number of dependants and the doctor’s information. If the patient is approved at this step then a presumptive 30 day supply is sent to a pharmacy for the patient to pick up. Then a more detailed application is sent either to the patient or the doctor. This application is patient specific can can not be copied. The completed application must be mailed back.
Health Provider’s Role	The doctor must fill out a section that includes their DEA# and prescription information and sign the application.
Patient’s Role	The patient must provide detailed financial information and sign the application.
How Dispensed	A pharmacy card is sent to the patient to use once a month.
Amount Dispensed	11 months are allowed on the card.
Refills	After one year another application must be filled out.
Limit	Indefinitely

23. Bausch and Lomb Indigent Patient Program

Pharmaceutical Company	Bausch and Lomb
Program Name	Bausch and Lomb Indigent Patient Program
Program Address	PO Box 30450 Rochester, NY 14603-0450
Medicines On Program	Alrex, Lotemax
Phone Number	800-323-0000
Guidelines and Notes	Patients must be finacially disadvantaged and have no source of prescription drug coverage through private insurance or public assistance. The patient must have an annual household income of less than $9,000. for a single person or $14,000 for a combined family.
Initiating Enrollment	Anyone can call for the application and it will be faxed out. The completed application must be mailed back to the company.
Health Provider’s Role	The physican must fill out a section and include a prescription and a copy of the physician’s current license.
Patient’s Role	The patient only needs to tell the doctor they are in need.
How Dispensed	The medications are sent to the doctor’s office.
Amount Dispensed	The company sends out three bottles at a time.
Refills	When the patient is down to the last bottle a whole new application is needed.

24. Baxter Factor Plus Program

Pharmaceutical Company	Baxter Healthcare Corporation
Program Name	Baxter Factor Plus Program
Program Address	PO Box 4280 Gaithersburg, MD 20885-4280
Medicines On Program	Advate, Feiba VH, Hemofil-M AHF, Recombinate rAHF
Phone Number	800-548-4448, #2
Guidelines and Notes	A patient must be a US resident, have no insurance and be in financial need. In order for a patient to enroll in the program the facility or provider must also be enrolled as well. Once a facility or provider is enrolled once they do not need to do so again. The application has 3 sections, including an enrollement for the facility. It also has a replacement application (Form D). To get replacement medication the form must sent in through out the month but not before the 20th of the next month. This is only good for Hemofil M AHF, Recombinate rAHF, or FEIBA VH.
Initiating Enrollment	Once the facility has a Baxter Customer number someone from the facility or doctor’s office must call for a patient application and it will be sent out. Both applications can be copied. The completed application can be faxed or mailed back.
Health Provider’s Role	Form A is for the provider at the facility. It must be signed and dated, agreeing that the patient will be recieving the medication free of charge. Form C is for the phyisician to fill out at and sign. This form include a prescription sections.
Patient’s Role	Form B is for the patient to fill out and asked for detailed financial and income information. The patient must sign the application.
How Dispensed	Medication is sent to facility or the stated address.
Amount Dispensed	The maximium amount of replacement product a provider may receive is based on the patient’s hisorical average annual dose, not to exceed 80,000 units.
Refills	To get another supply fill out form D and sent in. Every year a new application is needed.
Limit	Indefinite

25. Bayer Patient Assistance Program

Pharmaceutical Company	Bayer Pharmaceuticals Corporation
Program Name	Bayer Patient Assistance Program
Program Address	PO Box 29209 Phoenix, AZ 85038-9209
Medicines On Program	Adalat CC, 30mg, Adalat CC, 60mg, Adalat CC, 90 mg, Avelox 400 mg, Avelox IV, Biltricide, Cipro 250mg, Cipro 500 mg, Cipro 750 mg, Cipro IV, Cipro XR, Domepaste Bandages, DTIC-Dome, Nimotop, Precose 100 mg, Precose 25mg, Precose 50 mg
Phone Number	800-998-9180, Opt 1
Guidelines and Notes	Patient must meet financial guidelines that re not disclosed. Patients cannot have prescription for the medications needed. Patient may also apply if the insurance has reached its cap.
Initiating Enrollment	Anyone may call as long as long as the person has all the financial, expense, and doctor’s information. The company takes most information over the phone and then sends the application to the doctor. They also supply the patient with a group number, ID number, and a process number so the patient can use them to get prescriptions in case of an emergency in the first 30 days. The completed application must be mailed back.
Health Provider’s Role	Doctor signs and dates application. Company authorizes additional use of card (beyond 30 days) once application is received.
Patient’s Role	Complete patient section of application and sign it.
How Dispensed	The company sends card with application for patient to bring to the pharmacy.
Amount Dispensed	Each application is good for up to six months.
Refills	After 6 months, a form is sent out that the doctor and patient needs to fill out and send back. After a new application is needed.
Limit	Indefinitely

26. Benefix Patient Assistance Program

Pharmaceutical Company	Genetics Institute, Inc.
Program Name	Benefix Patient Assistance Program
Program Address	5870 Trinity Parkway, Ste 600 Centerville, VA 20120
Medicines On Program	Benefix , ReFacto
Phone Number	888-999-2349
Guidelines and Notes	Patient must be uninsured and meet the following the financial guidelines: At or below $25,000 for a single person or $40,000 for a family. The company reviews each case individually. Amish patients are eligible for one year, non-Amish patient must reapply every three months.
Initiating Enrollment	Have health care provider call company and they will send application to doctor’s office or DME provider. The application is patient specific and can not be copied. Completed application can faxed back as long as the original is mailed in as well.
Health Provider’s Role	Doctor fills out physician section and signs the application.
Patient’s Role	Patient provide income information, household size and insurance information. Patient must also sign the application.
How Dispensed	Sent to physician’s office.
Amount Dispensed	Depends on the request; up to 3 months. (The max is 75000 units per year.)
Refills	Patient must requalify for the program every 90 days (unless Amish who are enrolled for one year.)
Limit	Indefinitely

27. Berlex Oncology Camcare

Pharmaceutical Company	Berlex Laboratories
Program Name	Berlex Oncology Camcare
Program Address	PO Box 221289 Charlotte, NC 28222-1289
Medicines On Program	Campath 30 mg, Fludara 50 mg, Leukine Liquid 500mcg, Leukine Lyphilized 250 mcg
Phone Number	800-473-5832
Guidelines and Notes	Hrs. 8:30-5 pm M-F Patient must be uninsured and be US citizen and fall within income guidelines, which are not disclosed If patient has insurance but it doesn’t cover these drugs, they must obtain proof of non-coverage and they will be considered on a case by case basis.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. The blank application can be copied. The completed application can be faxed or sent back.
Health Provider’s Role	Doctor complete a section and signs the application.
Patient’s Role	The patient needs to provide detailed financial information and documentation of lack of insurance. The patient also needs to sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The amount sent out varies depending on the medication and the patient’s needs. Fludara – up to 6 shipments up to 5 vials per month. Campath – 1 to 4 boxes (3 ampules/box) per month. Leukine – depends on how prescribed.
Refills	Doctor’s office calls company to attest patient still in need and the refills are sent out. A new application is needed every six months.
Limit	Indefinite

28. Berlex Patient Assistance Program

Pharmaceutical Company	Berlex Laboratories
Program Name	Berlex Patient Assistance Program
Program Address	PO Box 1000 M2/1-5 Montville, NJ 07045-1000
Medicines On Program	Betapace 120 mg, Betapace 160 mg, Betapace 240 mg, Betapace 80 mg, Betapace AF 120 mg, Betapace AF 180 mg, Betapace AF 80 mg, Climara 0.025 mg, Climara 0.0375 mg, Climara 0.05 mg, Climara 0.06 mg, Climara 0.075 mg, Climara 0.1 mg, Climara Pro 0.045/0.015mg
Phone Number	888-237-5394, option 6, option 1
Guidelines and Notes	Patient must be a US citizen. The patient must also be in one of the two following situations: 1- have an income of $20,000 or less and not be eligible for Medicare, Medicaid or any private or state programs. 2- have a household income of $15,000 or less and be eligible for the above programs but not have prescription coverage. There are three different applications, one for each medication. All the information needed is the same. The Patient Consent Form must be signed by the prescriber. There is also a Doctor/Prescriber Enrollment Form that the doctor has to fill out the first time they have a patient enrolling in the program, but not for any future patients. Once a patient is accepted into the program the doctor/perscriber’s office will be notified via US Mail. If the patient is not accepted, a denial letter with the reason for denial will be sent to the doctor’s office via US Mail.
Initiating Enrollment	They prefer that the doctor/prescriber’s office start the process, but anyone can call for an application which will be sent to the doctor/prescriber’s office. If a patient calls, have the doctor/prescriber’s fax and phone number and the name of the person to whom the fax will be sent. The application can be copied. The completed application can be faxed or mailed back.
Health Provider’s Role	Doctor completes and signs both the doctor/prescriber enrollment and patient enrollment forms. No stamps accepted. Most of the communications between the company and the office will be via fax.
Patient’s Role	The patient must fill out the Patient Enrollment form with regards to Annual Gross Family Income and Martial Status, check all the appropriate boxes and sign the Patient Consent Form and provide proof of income.
How Dispensed	Medication is sent to the doctor/prescriber’s office within a week to 10 days of acceptance. Please include street address and suite number as well as Post Office box for corrrespondence
Amount Dispensed	A three month supply is sent at one time.
Refills	A Quarterly Product Request form is sent to the doctor/perscriber’s office that needs to be filled out for refills. If there has been a change to dose or strength a prescription must be included with the form. After a year, the doctor/prescriber’s office will receive a new application that must be completely filled out with current information and signed by both patient and prescriber.
Limit	Indefinitely

29. Bertek Patient Assistance Program

Pharmaceutical Company	Bertek Pharmaceuticals, Inc.
Program Name	Bertek Patient Assistance Program
Program Address	PO Box 4310 Morgantown, WV 26504-4310
Medicines On Program	Clorpres, Maxzide, Maxzide-25 mg, Nitrek 0.2 mg/hr, Nitrek 0.4 mg/hr, Nitrek 0.6 mg/hr, Phenytek
Phone Number	888-823-7835
Guidelines and Notes	This program is designed to be a temporary program. Patients must be US citizens or documented legal aliens and not be eligible for Medicaid or any third party prescription coverage.The patient must also be within the Federal Poverty Guidelines. One page of the application is a Waiver and Release of Liability. This needs to be signed by the patient and two witnesses.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. The application can be copied. The completed application must be mailed back in.
Health Provider’s Role	The doctor must complete a section, sign and attach a prescription.
Patient’s Role	The patient must fill out a section, sign and attach a copy of proof of income. One page of the application is a Waiver and Release of Liability. This needs to be signed by the patient and two witnesses.
How Dispensed	The medication is sent to the doctor’s office. Patients needing Clozaril, Ritalin LA and Focalin are sent a retail card which is taken to the pharmacy.
Amount Dispensed	The medication is sent out in a 90 day supply. FOr Clorpres, Maxzide and Phenytek requests will be filled with stock bottle of 100. For Nitrek, requests will be filled with stock bottle of 30.
Refills	A new prescription is need for refills. A whole new application with documentation is needed after one year.
Limit	Unspecified

30. Betaseron Foundation

Pharmaceutical Company	MS Pathways
Program Name	Betaseron Foundation
Program Address	MS Pathways PO Box 221349 Charlotte, NC 28222
Medicines On Program	Betaseron
Phone Number	800-948-5777
Guidelines and Notes	The patient must be US resident and must meet financial guidelines that are not disclosed. The support program is very detailed including registered nurse counselors who are available 24 hours a day, seven days a week. They also provide training if needed. There is a co-pay for each shipment ranging from $5.00-$35 .00
Initiating Enrollment	They prefer for the patient to call so they can get a lot of the information they need; if patient can’t call, OK for relative or provider who knows patient to call. Patient is registered over the phone, and part of application is sent to the doctor and another part to the patient.
Health Provider’s Role	Doctor completes, signs, and attaches a prescription.
Patient’s Role	The patient must fill out a section on financial and insurance information, sign the application and attach proof of income.
How Dispensed	Sends the medication to address where patient will be able to sign for it (usually home or work). There is a co-pay for each shipment ranging from $5.00-$35.00
Amount Dispensed	A shipment of 30 days is sent.
Refills	To get a refill, the patient must call in when only 5 doses are left or the company will call. After one year a whole new application is needed.
Limit	Unspecified

31. Biovail Patient Assistance Program

Pharmaceutical Company	Biovail Pharmaceuticals, Inc.
Program Name	Biovail Patient Assistance Program
Program Address	PO Box 836 Somerville NJ 08876
Medicines On Program	Betaseron Foundation
Phone Number	866-268-7325
Guidelines and Notes	Patient must have already been enrolled and receiving Cardizem from the patient assistance program that was previously available through Aventis; no new applications will be accepted for any form of Cardizem. New patients can apply for Teveten and Zovirax. The patient must be a legal resident of the US. Patent can’t have any third party coverage for prescriptions from public or private sources. Patient’s household income must be less 200% of the federal poverty level. If you have questions, call between 9-5 pm EST.
Initiating Enrollment	Call for form; they will automatically fax it. Completed application must be mailed back.
Health Provider’s Role	Doctor completes a section, signs it, and attaches a prescription for a 3 month supply and indicates whether or not this is a new or refill application. For Zovirax one tube per request.
Patient’s Role	The patient must fill out section as well, sign it and attach proof of income.
How Dispensed	Allow 4-6 weeks for approval of applictation. Medication will be delivered to practitioner’s office.
Amount Dispensed	3 month supply.
Refills	Use same form and indicate that it is a repeat application.
Limit	Indefinitely, but they state they may discontinue the program at any time.

32. Blaine Patient Assistance Program

Pharmaceutical Company	Blaine Company, Inc.
Program Name	Blaine Patient Assistance Program
Program Address	PO Box 430 Hackettstown, NJ 07840
Medicines On Program	Mag-Ox 400 mg, Uro-Mag 140 mg capsule
Phone Number	800-503.7747
Guidelines and Notes	The patient must be a US resident, and meet financial guidelines that are not disclosed.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. An application can also be filled out on line at Rxhope.com The application can be copied. THe completed application can be faxed back to the company
Health Provider’s Role	The doctor must fill out a section and sign it.
Patient’s Role	The patient needs to provide information but a patient signature is not needed.
How Dispensed	The medication will be sent to the patient’s house unless otherwise noted.
Amount Dispensed	The medication is sent in a four month supply.
Refills	The medication is sent out automatically sent out until the year is over and then a new application is needed.
Limit	Not Applicable

33. Boehringer Ingelheim Care Foundation Patient Assistance Program

Pharmaceutical Company	Boehringer Ingelheim Pharmaceuticals, Inc.
Program Name	Boehringer Ingelheim Care Foundation Patient Assistance Program
Program Address	c/o ESI/SDS PO Box 66555 St. Louis MO 63166
Medicines On Program	Aggrenox, Atrovent Inhalation Aerosol, Atrovent Nasal Spray, Catapres-TTS Transdermal Patch, Combivent, Flomax Capsules, Micardis HCT, Micardis Tablets, Mirapex, Mobic, Viramune Oral Suspension, Viramune Tablets
Phone Number	800-556-8317
Guidelines and Notes	Income guidelines for this program is at 200% of the Federal Poverty Guidelines. Patient must be US citizen and resident, have no complete or partial prescription insurance coverage, and income must be at or below their guidelines.
Initiating Enrollment	Anyone can call to start the process, but must be 18 years or older. The blank application can be copied.
Health Provider’s Role	Doctor completes, signs, and fills out the prescription built into the application.
Patient’s Role	The patient needs to provide prood of household income, and send in a tax return if filed. The patient must also sign the application.
How Dispensed	The company sends medicine to doctor’s office in 2-3 weeks.
Amount Dispensed	The medication is sent out in up to a three month supply.
Refills	To get a refill send copy of application and refill prescription. Once a year a whole new application with proof income is needed.
Limit	Indefinitely.

34. National Organization for Rare Disorders (NORD)

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Botox Patient Assistance Program
Program Address	Botox Patient Assistance Program C/O NORD PO Box 8923 New Fairfield, CT 06812-8923
Medicines On Program	Botox
Phone Number	800.530.6680
Guidelines and Notes	The patient must be a US citizen or legal resident and have no insurance for Botox. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone may call to start the process, the application will be mailed to the patient, doctor or social worker. The completed application should be mailed back.
Health Provider’s Role	The doctor completes a section, signs and attaches a prescription to the application.
Patient’s Role	Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	Depends on amount awarded to patient,
Refills	New application only needed annually.
Limit	Indefinitely

35. Bradley Pharmaceuticals Indigent Patient Program

Pharmaceutical Company	Bradley Pharmaceuticals, Inc.
Program Name	Bradley Pharmaceuticals Indigent Patient Program
Program Address	383 Route 46 West Fairfield NJ, 07004 Attn: Indigent Patient Program
Medicines On Program	Anamantle HC Cream 3%, Brontex III Tablets, Brontex Syrup, Carmol Cream 40 1oz, Carmol Cream 40 3oz, Carmol Cream 40 7oz, Carmol Gel 15ml, Carmol Lotion 8oz, Carmol Scalp Treatment Kit, Carmol Scalp Treatment Lotion 3 oz, Deconamine Capsules 60mg, Deconamine SR 120mg, GlutoFac-MX , GlutoFac-ZX, LidaMantle Cream 3oz, LidaMantle HC Cream 3oz, LidaMantle HC Lotion 177 ml, LidaMantle Lotion 177 ml, Pamine 2.5ml Tablet, Pamine 5 ml Tablet , Rosula Cleanser 355ml, Rosula Gel 1.5 oz , Tyzine Nasal 30ml, Tyzine Nasal Drops 15ml, Tyzine Nasal Solution 30ml, Tyzine Nasal spray 15ml
Phone Number	800-929-9300
Guidelines and Notes	The patient must have an annual income of less than $25,000 for a family of two and be a resident of the US.
Initiating Enrollment	Anyone can call to start the process with the patient and doctor’s basic information. The company will then send the partially completed application to the doctor’s office to be finished. The completed application can be faxed or mailed back in.
Health Provider’s Role	The phyisician must complete and sign a section of the application and include a prescription for up to 90 days. The physician should write the following on the prescription, “Prescription of Indigent.”
Patient’s Role	The patient provides Social Security Number, Annual Income and basic information. The patient does not need to sign the application
How Dispensed	The medications are sent to the phyisician’s office.
Amount Dispensed	The medication is sent out in a 90 day supply.
Refills	For a refills, the doctor must send in a prescription. After one year a whole new application is needed.
Limit	Indefinitely.

36. Bridge Program for Genotropin

Pharmaceutical Company	Pfizer, Inc.
Program Name	Genotropin
Program Address	3168 Riverport Tech Center Drive Maryland Heights, MO 63043
Medicines On Program	Genotropin
Phone Number	800-645-1280, option 3
Guidelines and Notes	Patient must be a US resident, have no insurance and met in-house financial guidelines. The patient must need the medication for FDA approved diagnosis.
Initiating Enrollment	Anyone can call to get an application, The Statement of Medical Necessity, sent out. There are two applications: one for adults and one for children.
Health Provider’s Role	The doctor must fill out the Statement of Medical Necessity, sign and attach a prescription. For children, a growth chart is also required.
Patient’s Role	Once the Statement of Medical Necessity is sent in, the company wiill contact the patient. The patient must provide proof of income.
How Dispensed	Medication is sent to patient or doctor’s office but someone must be there to sign for the medication.
Amount Dispensed	Medication is sent out one month at a time.
Refills	The patient must call for a refill. After a year the company will need updated insurance and financial information.
Limit	Indefinitely.

37. Bristol Meyers Squibb Patient Assistance Program for Abilify

Pharmaceutical Company	Bristol-Myers Squibb Company
Program Name	Bristol Meyers Squibb Patient Assistance Program for Abilify
Program Address	PO Box 29020 Phoenix AZ 85038-9020
Medicines On Program	Abilify
Phone Number	800-736-0003, opt 1
Guidelines and Notes	Call between the hours of 9am and 6pm EST. Patient must be a US resident and be at or below 200% of the Federal Poverty Guidelines. The patient must also meet certain insurance guidelines that the company does not disclose.
Initiating Enrollment	Anyone can call for an application and it be mailed or faxed out. The blank application can be copied. The completed application can be mailed or faxed back.
Health Provider’s Role	Doctor fills out a section with basic information included DEA and state lincense number. The doctor must sign the application as well.
Patient’s Role	Provide basic personal, insurance, income and expense information and sign form.
How Dispensed	The medication is sent to physician.
Amount Dispensed	A ninty day supply is sent out.
Refills	A form is mailed to the doctor’s office, it needs to be sent back with doctor’s signature to get refilled. After a year a new application is needed.
Limit	indefinitely

38. Bristol-Meyers Squibb Access Access Program

Pharmaceutical Company	Bristol-Myers Squibb Company
Program Name	Bristol-Meyers Squibb Access Access Program
Program Address	6900 College Blvd., Suite 1000 Overland Park, KS 66211-9840
Medicines On Program	BiCNU, Blenoxane, CeeNU, Cytoxan I.V., Cytoxan tablets 25 mg, Cytoxan tablets 50mg, Droxia, Etopophos, Hydrea, Ifex, Lysodren, Megace Oral Suspension, Mesnex, Mutamycin, Paraplatin, Platinol-AQ, Reyataz, Sustiva, Taxol, Teslac, Vepesid Capsules, Vepesid I.V., Videx, Videx EC, Vumon, Zerit, Zerit Oral Solution
Phone Number	800-272-4878
Guidelines and Notes	Patients must have no insurance coverage for prescription needed. The patient must be treated out-patient and treated on an ongoing process. Patients must also meet financial guidelines that are not disclosed. Call between 8-5pm CST.
Initiating Enrollment	The doctor’s office should call for an application, the application will be faxed out. If application is downloaded from NeedyMeds the doctor’s office must call before the application is sent in. A case number is needed or the application is invalid. The completed application can be mailed or faxed back.
Health Provider’s Role	The doctor must fill out a section and sign the application. Once the application is filled out the doctor must call the company to get the patient’s unique case number and instruction on sending the application in.
Patient’s Role	The patient or patient advocate needs to fill out a section with financial and insurance information. The must also sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	For the oncology medications a 2 month supply is sent out. For the virology medications a three month supply. Hydrea and Cytoxan Tablets are sent out in a 6 month supply.
Refills	With the supply is a fax that the doctor must fill out and sent back to get refills. A new application is need every six months for all the medications except Cytoxan Tablets and Hydrea which need new applications once a year.
Limit	Indefinitely as long as drug needed.

39. Bristol-Myers Squibb Patient Assistance Foundation

Pharmaceutical Company	Bristol-Myers Squibb Company
Program Name	Bristol-Myers Squibb Patient Assistance Foundation
Program Address	PO Box 52112 Phoeniz, AZ 85072-2112
Medicines On Program	Avalide Tablet 150 mg/12.5, Avalide Tablet 300 mg/12.5 mg, Avapro Tablet 150 mg, Avapro Tablet 300 mg, Avapro Tablet 75 mg, BuSpar Dividose Tablet 15 mg, Cefzil Oral Suspension 125mg/5 ml, Cefzil Oral Suspension 250 mg/5ml, Cefzil Tablet 250 mg, Cefzil Tablet 500 mg, Coumadin Tablet 1 mg, Coumadin Tablet 10 mg, Coumadin Tablet 2 mg, Coumadin Tablet 2.5 mg, Coumadin Tablet 3 mg, Coumadin Tablet 4 mg, Coumadin Tablet 5 mg, Coumadin Tablet 6 mg, Coumadin Tablet 7.5 mg, Desyrel Dividose Tablet 150 mg, Desyrel Dividose Tablet 300 mg, Dovonex topical cream .005%, Dovonex topical ointment .005%, Dovonex topical solution .005%, Glucophage Tablet 1000 mg, Glucophage Tablet 500 mg, Glucophage Tablet 850 mg, Glucophage XR Tablet 500 mg, Glucophage XR Tablet 750 mg, Glucovance tablet 1.25 mg/250 mg, Glucovance tablet 2.5 mg/500 mg, Glucovance tablet 5 mg/500 mg, K-Lyte CL tablet eff 25 meq, K-Lyte DS Tablet eff 50 meq, K-Lyte Tablet eff 25 meq, Kenalog .05% cream 20g topical cream .1%, Kenalog .1% cream 15g topical cream .1%, Kenalog .1% cream 60g topical cream.1%, Kenalog .1% cream 80g topical cream .1%, Kenalog .1% lotion 60 ml topical lotion .1%, Kenalog .1% ointment 15g topical ointment .1%, Kenalog .1% ointment 60 g topical ointment .1%, Kenalog 10 5 ml vial 10 mg/ml, Kenalog 40, 1 ml vial 40 mg/ml, Kenalog aerosol topical spray .1%, Kenalog in oralpaste 0.1%, Klotrix Tablet sa 10 meq, Lac-Hydrin Topical Cream 12%, Lodosyn Tablet 25 mg, Metaglip 2.5 mg/250mg, Metaglip 2.5 mg/500mg, Metaglip 5.0mg/500mg, Monopril HCT Tablet 10/12.5 mg, Monopril HCT Tablet 20/12.5 mg, Monopril Tablet 10 mg, Monopril Tablet 20 mg, Monopril Tablet 40 mg, Naturetin Tablet 5 mg, Plavix Tablet 75 mg, Pravachol Tablet 10 mg, Pravachol Tablet 20 mg, Pravachol Tablet 40 mg, Pravachol Tablet 80 mg, Pravigard PAC tablet 325 mg/20 mg, Pravigard PAC tablet 325 mg/40 mg, Pravigard PAC tablet 325 mg/80 mg, Pravigard PAC tablet 81 mg/20 mg, Pravigard PAC tablet 81 mg/40 mg, Pravigard PAC tablet 81 mg/80 mg, Prolixin Elixir .5mg/ml, Prolixin Oral Concentrate 5 mg/ml, Prolixin Tablet 10 mg, Prolixin Tablet 5 mg, Pronestyl Capsule 250 mg, Pronestyl Tablet 375 mg, Pronestyl Tablet 500 mg, Pronestyl-SR Tablet 500, Sinemet Tablets 10 mg/100 mg, Sinemet Tablets 25mg/100 mg, Sinemet Tablets 25mg/250 mg, Tequin Tablets 200 mg, Tequin Tablets 400 mg, Tequin Tablets Teq-Paq 400 mg, Ultravate Topical Cream .05%- Jar 15 g, Ultravate Topical Ointment .05%- Jar 50 g, Ultravate Topical Ointment .05%- Tube 15 g, Vasodilan Tablet 10 mg, Vasodilan Tablet 20 mg
Phone Number	800-736-0003, ext 2
Guidelines and Notes	Call Monday through Friday 9-6PM Eastern Time. There is a separate program for the oncology. Patient must be a US Citizen or legal resident alien. Physician and patient are notified regarding acceptance or denial of application. The address on the application must be the same as the address listed with the DEA number of the prescriber.
Initiating Enrollment	Doctor or patient can call for form which will be automatically faxed 24 hours a day. A The completed application can be mailed or faxed back.
Health Provider’s Role	Doctor completes physician section which includes DEA# and signs form including the RX section which takes the place of a prescription. There is a list of drugs and the “NDC Number” for the drug must be on the form as well as the name of the drug.
Patient’s Role	Provide basic information including gross monthly income and size of household, and whether or not patient has public or private prescription insurance and sign form.
How Dispensed	The medication is sent to the prescriber.
Amount Dispensed	The first shipment is sent in a 6 month supply, then the next two shipments are sent in 90 day supplies.
Refills	Patient or doctor need to call to get refills. A new application can be used to change the dosage for an existing patient; the physician would indicate that on the prescription section of the form. Once a year a whole new application is needed.
Limit	Indefinitely

40. Buphenyl And Urea Cycle Treatment Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Buphenyl And Urea Cycle Treatment Assistance Program
Program Address	C/O NORD PO Box 1968 Danbury, CT 06813-1968
Medicines On Program	Buphenyl, Urea Cycle Therapy
Phone Number	800.711.0811
Guidelines and Notes	Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening an applicatoin is sent to the patient, case worker or phyisician. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section and sign.
Patient’s Role	The patient must fill out a section about financial and insurance information. The patient may be required to provide proof of income. The patient also needs to sign the application.
How Dispensed	The medication is sent via a mail order pharmacy to the patient’s house.
Amount Dispensed	Amount sent depends on the amount awarded to the patient.
Refills	New applications are needed annually.
Limit	Indefinitely

41. Busulfex Patient Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Busulfex Patient Assistance Program
Program Address	Busulfex Patient Assistance Program C/O NORD PO Box 1968 New Fairfield, CT 06812-8923
Medicines On Program	Busulfex
Phone Number	800.999.6673
Guidelines and Notes	The patient must be a US citizen or legal resident and have no insurance for the medication. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assistance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone may call to start the process, the application will be mailed to the patient, doctor or social worker. The completed application should be mailed back.
Health Provider’s Role	The doctor completes a section, signs and attaches a prescription to the application.
Patient’s Role	Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the form.
How Dispensed	Medication is sent to the doctor’s office.
Amount Dispensed	Depends on amount awarded to patient.
Refills	New application only needed annually.
Limit	Indefinitely

42. Cancer Support Network for Iressa

Pharmaceutical Company	Astra Zeneca Pharmaceuticals
Program Name	Cancer Support Network for Iressa
Program Address	ot Applicable
Medicines On Program	Iressa 250 mg
Phone Number	866-992-9276, opt #1
Guidelines and Notes	To get assistance for Iressa, patients must first call the Reimbursment Network. This specialist will try to find funding sources for the patient. If there is no funding for the patient. Then an application will be sent out with a required code on it. The rest of the application process is then handled through the Astra Zeneca Foundation Patient Assistance Program.
Initiating Enrollment	The doctor or patient can call to start the prescreening done over the phone. The caller needs to have insurance, medical and household income for the patient.
Health Provider’s Role	Doctor completes and signs a section of the application. A prescription must be attached or fill out the prescription information on the appilcation.
Patient’s Role	The patient must fill out the patient section and sign it. They must also attach proof of income and either a denial letter from Medicaid or a copy of the Medicaid card.
How Dispensed	The medication can be sent to either the patient or the doctor.
Amount Dispensed	A three month supply.
Refills	20 to 30 days before the medication runs out, the patient must call the number on the medication bottle for a refill. Totally new applications needed once a year. A re-application is sent 45 days prior to one year expiration date.
Limit	Indefinitely.

43. Care First and Compehensive Care Program

Pharmaceutical Company	Axcan-Scandipharm, Inc
Program Name	Care First and Compehensive Care Program
Program Address	PO Box 52065 Phoenix AZ, 85072-9152
Medicines On Program	Ultrase EC, Ultrase MT12
Phone Number	1-866-292-2679, opt 1
Guidelines and Notes	There are two components to this program. The first is the Care First Program. This is available to children under two years of age with cystic fibrosis. The Comprehensive Care Program provides ScandiShake or ScandiCal, ADEKs viamin drops or tablets and a flutter device (if prescribed) to patients over 2 years old who are taking Ultrace. Once a patient is enrolled in the Care First Program they will recieve more details about the Compehensive Care Program when the patient turns two. The patient must send in the receipts from the Ultrace to get the supplements which are mailed to the patients home. In order to get more, just send in more receipts. The amount sent matches the amount of Ultrace taken.
Initiating Enrollment	The enrollment is done over the phone. Anyone can call as long as have the proper information which included doctor’s name address, phone number, patient home number, parent name, home address.
Health Provider’s Role	NA.
Patient’s Role	Patient only needs to be in need.
How Dispensed	For the Care First, the patient is given an ID number and group number which is taken to the pharmacy and the patient is given the medication.
Amount Dispensed	The patient gets either a 30 or 90 supply at one time from the pharmacy. Once the patient is enrolled they just go back to the pharmacy for refills.
Refills	Once the patient is enrolled they just go back to the pharmacy for refills. Until the patient turns two, s/he is in the program.
Limit	Indefinitely.

44. Carnitor Drug Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Carnitor Drug Assistance Program
Program Address	Carnitor Drug Assistance Program C/O NORD PO Box 1968 New Fairfield, CT 06812-8923
Medicines On Program	Carnitor Injection 1gm/5ml, Carnitor Injection 200 mg/ml, Carnitor Oral Solution , Carnitor Tablets 330mg
Phone Number	800.999.6673
Guidelines and Notes	The patient must be a US citizen or legal resident and have no insurance for the medication. The patient must also demonstrate having a legal prescription for Carnitor. If patient is a minor then the families income information is also needed. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assistance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone may call to start the process, the application will be mailed to the patient, doctor or social worker. The completed application should be mailed back.
Health Provider’s Role	The doctor completes a section, signs and attaches a prescription to the application.
Patient’s Role	Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the form.
How Dispensed	Medication is sent directly to the patient through a mail order pharmacy.
Amount Dispensed	A 90 day supply is sent at one time
Refills	New application is needed annually.
Limit	Indefinitely

45. Celgene Therapy Patient Assistance Program

Pharmaceutical Company	Celgene Corporation
Program Name	Celgene Therapy Patient Assistance Program
Program Address	6900 College Blvd. Suite 1000 Overland Park, KS 66211
Medicines On Program	Thalomid
Phone Number	888-423-5436, #3
Guidelines and Notes	Patient must have no insurance that covers the drug or they have maxed out their drug insurance benefits. Patient must meet the companies finanical guidelines that are not disclosed. They make and fax determination with instructions in two buisness days and also call to confirm the physician’s office.
Initiating Enrollment	Physician’s office must call to get an application faxed to the office. This application can be copied. Completed application can be faxed back.
Health Provider’s Role	Health care provider needs to sign and date a section of the application. Prescription is not needed until patient is approved for program. Once approved the company will contact the doctor for the perscription.
Patient’s Role	Patient must fill out a section of the application and sign and date. Photocopies of both the front and back of the patient’s health insurance card(s) must also be included.
How Dispensed	The company sends the medication to the doctor’s office.
Amount Dispensed	The medication is sent in a one 28 day cycle.
Refills	To get refills the doctor must fax a new prescription to 1-888-432-9325 dated no more than seven days before the next treatment date. Once the patient is accepted to the program, theyare in the program as long as they are continuously taking the medication. After three months of not using the medication a new application is needed.
Limit	Indefinitely

46. Celltech Patient Assistance Program

Pharmaceutical Company	Celltech Pharmaceuticals, Inc.
Program Name	Celltech Patient Assistance Program
Program Address	PO Box 430 Heckettstown, NJ 07840
Medicines On Program	Dipentum, Gastrocrom Oral Concentrate, Semprex-D, Zaroxolyn 10 mg, Zaroxolyn 2.5 mg, Zaroxolyn 5 mg
Phone Number	866-523-3994
Guidelines and Notes	Patients must not have any third party coverage and must meet stringent income guidelines. Patient household income must be no more than 150% of the federal poverty level. Make sure application is complete and that all required documentation is included.
Initiating Enrollment	Anyone can call to get an application. Doctor’s offices can also fill out the application at rxhope.com Completed application can be faxed back.
Health Provider’s Role	The doctor needs to complete a section, sign the application and attach a prescription.
Patient’s Role	The patient must fill out a section about income and insurance, sign and attach proof of income to application.
How Dispensed	Medications are sent to provider prescribing them, usually within four weeks of receipt of application.
Amount Dispensed	The medication is sent in a three month supply.
Refills	Use entirely new application, just like first time, sent in with proof of income and prescription.
Limit	Unspecified

47. Cenestin Patient Assistance Program

Pharmaceutical Company	Dura-Med Pharmaceuticals, Inc
Program Name	Cenestin Patient Assistance Program
Program Address	1878 Arena Drive Hamilton, NJ 08610
Medicines On Program	mg Tablets, Cenestin 0.3 mg Tablets, Cenestin 0.45 mg Tablets, Cenestin 0.625, Cenestin 0.9 mg Tablets, Cenestin 1.25 mg Tablets
Phone Number	800-425-3122
Guidelines and Notes	The patient must be a US resident who does not have insurance or any prescription coverage. The patient’s annual income must fall below $15,000 if single and $25,000 if married.
Initiating Enrollment	If someone calls for an application, the company take some information and faxes a patient specific application to the doctor’s office. Or a blank application can be filled out and returned. The completed application can be faxed or mailed back to the company
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section about insurance and income, and sign the application in two places.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The medication is shipped in a 100 day supply
Refills	To get refills the doctor or patient must call for a Requalification Form that must be filled out and sent back. After a year a whole new application is needed.
Limit	Indefinitely.

48. Cetylite Industries, Inc

Pharmaceutical Company	Cetylite Industries, Inc
Program Name	Cetylite Industries, Inc.
Program Address	PO Box 90006 Pennsauken, NJ 08110
Medicines On Program	Cetacaine
Phone Number	800-257-7740
Guidelines and Notes	They have an informal program; decisions are made on a case-by-case basis. They make Cetacaine spray, liquid and ointment which is used as a topical anesthetic to control pain.
Initiating Enrollment	Put request in writing on letterhead. and fax to them; if there’s a problem they will get back to you. They will help if they can.
Health Provider’s Role	Contact company.
Patient’s Role	Minimal information required, would be on-file already.
How Dispensed	not specified
Amount Dispensed	not specified
Refills	Not Applicable
Limit	Not Applicable

49. Charitable Access Program

Pharmaceutical Company	Genzyme Corporation
Program Name	Charitable Access Program
Program Address	500 Kendall St Cambridge, MA 02142
Medicines On Program	Aldurazyme, Ceredase, Cerezyme, Fabrayzyme
Phone Number	800-745-4447, ext 16634
Guidelines and Notes	The patient must also have one the three FDA approved diseases: Gaucher, Fabry, or MPS I Disease. The patient must have no insurance that will cover the medication, or have exhausted the insurance.
Initiating Enrollment	The doctor can call the company to get an application. The application is mailed out to the patient. The completed application needs to mailed back.
Health Provider’s Role	The doctor needs to complete a letter of intent to treat, and a statement of medical necessity.
Patient’s Role	The patient needs to fill out a section that asks for detailed financial and insurance information. The patient must also sign the application and need to submit the last three years of tax returns and last three months of bank statements.
How Dispensed	The medication is sent to the doctor’s office or infusion site.
Amount Dispensed	The amount sent depends on the patient’s medical needs. Aldurazyme is sent in a one week dose, the others are sent for an every other week doseage.
Refills	Refills are case by case, speak to the company once enrolled in the program.
Limit	N/a

50. Clozaril Patient Support Program

Pharmaceutical Company	Novartis Pharmaceuticals
Program Name	Clozaril Patient Support Program
Program Address	NA
Medicines On Program	Clozaril
Phone Number	800-257-3273, opt 1
Application
Guidelines and Notes	Before a patient can be enrolled both the patient and the doctor must be enrolled in the National Clozaril Registry (1-800-448-5938.) This is a one time, 12 week paperless program for Clozaril.
Initiating Enrollment	Patient advocate or doctor must call the company to give basic patient and doctor information. The company give the patient an ID number. And a card is sent to the doctor’s office. (84 days/12 week of therapy)
Health Provider’s Role	Just call in to start the process and enroll in National Clozaril Registry.
Patient’s Role	Enroll in National Clozaril Registry.
How Dispensed	The ID card is taken to a pharmacy to get the medication.
Amount Dispensed	Medication is given out in no more than a 14 day supply at one time.
Refills	The card is good for 12 weeks, the patient must just take the card back to get refills.
Limit	One time.

51. ConnecticsCare

Pharmaceutical Company	Connectics Corporation
Program Name	ConnecticsCare
Program Address	See Application for Mailing Address.
Medicines On Program	Luxiq Foam, Olux Foam , Soriatane
Phone Number	888-500-3376
Fax Number	N/A
Application	Contact program for application
Guidelines and Notes	The patient must be a US resident with no perscription coverage through a public or private program. The patient’s income must be at or below 200% of the current Federal Poverty Level. The doctor can also request rebate certificates from her/his drug representative. These certificates can be given out with a prescription for Luxiq or Olux. The certificate is good for half of what the patient pays up to $25.00. The company also has an insurance verification program, to get reach that department call 1-800-572-3225. They refuse to give us any updated information, this information is current as of November 2003.
Initiating Enrollment	The doctor’s office must call to get a patient specific application mailed to the doctor’s office. The completed application must be mailed back.
Health Provider’s Role	The doctor must fill out a section and sign it.
Patient’s Role	The patient must also sign the application.
How Dispensed	The medication sent to the doctor’s office.
Amount Dispensed	A three month supply is out.
Refills	A new application is needed for each refill.
Limit	Indeinitely

52. Connections for Growth

Pharmaceutical Company	Serono Laboratories, Inc.
Program Name	Connections for Growth
Program Address	1 Technology Place Rockland MA 02370
Medicines On Program	Saizen
Phone Number	800-582-7989
Guidelines and Notes	This is a last resort patient assistance program. The company first works with the patient’s insurance to get the medication covered and/or appeal denials. The patient’s family meet financial critera that are not disclosed.
Initiating Enrollment	The doctor must start the process, by referring the patient to the company. The completed application can be faxed or mailed back into the company.
Health Provider’s Role	The doctor must approve of medication being sent.
Patient’s Role	The guardian must fill out the application, sign and attach proof of income and medical documents.
How Dispensed	The medication is sent to a doctor’s office.
Amount Dispensed	The medication is sent in a 3 month supply, unless the doctor notes otherwise.
Refills	The patient must call the company to get a refill at least 10 days before supply runs out. The company contacts the doctor for update and to get a new prescription. Every year a new application with documentation.
Limit	Indefinitely

53. Copaxone Patient Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Copaxone Patient Assistance Program
Program Address	C/O NORD PO Box 1968 Danbury, CT 06813-1968
Medicines On Program	Copaxone
Phone Number	800.887.8100
Guidelines and Notes	Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening an applicatoin is sent to the patient, case worker or phyisician. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section and sign.
Patient’s Role	The patient must fill out a section about financial and insurance information. The patient may be required to provide proof of income. The patient also needs to sign the application.
How Dispensed	The medication is sent via a mail order pharmacy to the patient’s house.
Amount Dispensed	Amount sent depends on the amount awarded to the patient.
Refills	New applications are needed annually.
Limit	Indefinitely

54. Cystadane Patient Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Cystadane Patient Assistance Program
Program Address	C/O NORD PO Box 1968 Danbury, CT 06813-1968
Medicines On Program	Cystadane
Phone Number	800.999.6673
Guidelines and Notes	Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening an application is sent to the patient, case worker or phyisician. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section about financial and insurance information. The patient may be required to provide proof of income. The patient also needs to sign the application.
How Dispensed	The medication is sent via a mail order pharmacy to the patient’s house.
Amount Dispensed	Amount sent depends on the amount awarded to the patient.
Refills	New applications are needed annually.
Limit	Indefinitely

55. Dermik Laboratories Patient Assistance Program

Pharmaceutical Company	Dermik Laboratories, Inc
Program Name	Dermik Laboratories Patient Assistance Program
Program Address	PO Box 651 Somerville NJ, 08876
Medicines On Program	BenzaClin Topical Gel 25 gr, Benzagel 42.5 gram Tube, Benzagel Wash 60 gram tube, Benzamycin Topical Gel 46.6 gram jar, Carac Cream 30 gram tube, Hytone Cream 56.8 gram tube, Hytone Lotion 59 mL Bottle, Klaron Lotion 4 oz, Noritate Cream 30 gram Tube, Penlac 6.6 mL, Psorcon Cream 60 gram Tube, Psorcon E Cream 60 gram Tube, Psorcon E Ointment 60 gram Tube, Psorcon Ointment 60 gram Tube, Sulfacet-R 25 gram Bottle, Vytone Cream 28.4 gram Tube
Phone Number	866-268-7326
Guidelines and Notes	A patient must be a US resident and cannot have or qualify for any goverment perscription coverage or any state or local programs. A patient cannot have or quailfy for any private prescription coverage such as HMO or PPO. The total annual household income must be at or below 200% of the Federal Poverty Level.
Initiating Enrollment	Anyone can start the process, and the application will be faxed out. It can be copied. The application must be mailed in.
Health Provider’s Role	The doctor must fill out a section that includes DEA#, a prescription for a max of three months, and sign the form.
Patient’s Role	The patient must fill out a section and sign it. They must also provided a copy of a tax return or proof of income.
How Dispensed	The medication is sent to the doctor’s office. Allow 4 weeks for processing.
Amount Dispensed	A three month supply is sent, each drug has different quantities but it very clearly outlined on the application.
Refills	Every three months a new application and prescription must be sent in. But the proof of income is only required once a year.
Limit	Indefinitely

56. Dexferrum Reimbursement Hotline and Patient Assistance Program

Pharmaceutical Company	American Regent, Inc.
Program Name	Dexferrum Reimbursement Hotline and Patient Assistance Program
Program Address	C/O InteleCenter PO Box 4280 Gaithersburg, MD 20885-4133
Medicines On Program	Dexferrum
Phone Number	800-282-7712, Opt 2
Guidelines and Notes	The patient must be a US resident, and be taking the medication for an FDA approved diagnosis. The company also has income and insurance guidelines that they do not disclose. This is a product replacement program
Initiating Enrollment	The doctor or treatment center must start to get an application faxed out. The completed application can be faxed back.
Health Provider’s Role	The doctor needs to fill out a section and sign it.
Patient’s Role	The patient also needs to filil out a section and sign it.
How Dispensed	The medication is sent to the treatment center.
Amount Dispensed	The amount requested is the amount sent.
Refills	The patient is enrolled for a year, after which a new application is needed. A product replacement form is needed for refills and are sent out once a patient is accepted into the program.
Limit	Indefinitely

57. Digestive Care, Inc Assistance Program

Pharmaceutical Company	Digestive Care, Incorporated
Program Name	Digestive Care, Inc Assistance Program
Program Address	1120 Win Drive Bethlehem, PA 18017
Medicines On Program	Pancrecarb MS 16 DR
Phone Number	Not Applicable
Guidelines and Notes	The patient must not be covered by medical insurance, Medicaid or other third party payers. Eligibility is determined on a case-by-case basis.
Initiating Enrollment	The physician submits a written request outlining the situation and indicate what assistance is needed. The letter must be mailed in.
Health Provider’s Role	See Above.
Patient’s Role	The patient needs to tell her/his doctor that s/he cannot afford the medication, and have no insurance.
How Dispensed	The medication is sent to the physician’s office. The medication will be shipped within 5 business days.
Amount Dispensed	The normal amount sent out is a 3 month supply.
Refills	If refills are needed another originial request must be submitted, after 3 months.
Limit	Unspecified

58. Doxil Reimbursement Solutions

Pharmaceutical Company	Ortho Biotech Products, L.P.
Program Name	Doxil Reimbursement Solutions
Program Address	PO Box 1016 San Bruno CA 94066
Medicines On Program	Doxil
Phone Number	800-609-1083, opt 1
Guidelines and Notes	The company provides insurance verification. But the program is for patients who meet their financial guidelines, which they don’t release and must be have no insurance or have reached their insurance limits.
Initiating Enrollment	Anyone can call to get an application, and it will be faxed out. The blank application can be copied. The completed application can be faxed.
Health Provider’s Role	Provide medical information and sign the application.
Patient’s Role	Patient must provide proof of income and sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The medication is sent out one month at a time.
Refills	After three weeks the company call the doctor’s office to see if a refill is needed, if so another supply is sent out. After six months another application is fiilled out and sent in, but unless changes have occured, no need to send in proof of income. Proof of income is only needed once a year.
Limit	indefinitely

59. ECR Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	ECR Pharmaceuticals
Program Name	ECR Pharmaceuticals Patient Assistance Program
Program Address	PO Box 71600 Richmond, VA 23255
Medicines On Program	Anaplex DM Cough Syrup, Anaplex HD Cough Syrup, Bupap, Dexpak , Lodrane 12 D, Lodrane 12 hour , Lodrane liquid, Nasatab LA tablets, Panalgesic Gold cream, Panalgesic Gold liniment, Pneumotussin 2.5 cough syrup, Pneumotussin tablets
Phone Number	800-527-1955
Guidelines and Notes	This is an informal program with no application
Initiating Enrollment	Doctor writes letter on letterhead stating patient’s need and lack of prescription coverage, attaches prescription or just explains situation to representative and gives him or her prescription for the patient.
Health Provider’s Role	See above.
Patient’s Role	No patient information needed.
How Dispensed	Sends medicine to doctor’s office.
Amount Dispensed	One bottle of 100.
Refills	To get refills the doctor must write a new letter.
Limit	Unspecified

60. Eldepryl Patient Rewards Program

Pharmaceutical Company	Somerset Pharmaceuticals, Inc.
Program Name	Eldepryl Patient Rewards Program
Program Address	2202 North Westshore Blvd., Ste. 450 Tampa, FL 33607
Medicines On Program	Eldepryl
Phone Number	800-892-8889
Guidelines and Notes	This is a rewards program –after purchase of two months supply of Eldepryl send in receipt and they will send a free month-supply. Patients can use this program indefinitely. They will gladly send brochures for patients.
Initiating Enrollment	Patient can call in for form that needs to be filled out. For every two receipts, patient can get a third bottle free. The completed form must be mailed in with a prescription.
Health Provider’s Role	N/A
Patient’s Role	Ask pharmacist for “duplicate prescription receipt” indicating purchase of Eldepryl. Obtain additional one month prescription from prescriber. Fill out self-mailer, attach prescription and send in.
How Dispensed	The medication is sent to the patient’s house.
Amount Dispensed	A one month supply is sent in.
Refills	Repeat the process after buying two more months supply.
Limit	Indefinitely

61. Eloxatin Reimbursement Hotline

Pharmaceutical Company	Sanofi-Synthelabo Pharmaceuticals, Inc.
Program Name	Eloxatin Reimbursement Hotline
Program Address	C/O Sanofi 90 Park Ave. New York, NY 10016
Medicines On Program	Eloxatin
Phone Number	877.435.6928 opt 5
Fax Number	877.366.0584
Application	Contact program for application
Guidelines and Notes	The patient must be enrolled before receiving treatment. (There is no retroactive reimbursement.) The patient must meet financial guidelines which are not disclosed and must be a US resident that cannot qualify for any public assistance programs.
Initiating Enrollment	The company prefers that the doctor calls to get the application. The application is faxed to the doctor. The completed application can be faxed back to the company.
Health Provider’s Role	The doctor must fill out a section, sign it and attach a prescription.
Patient’s Role	The patient must fill out a section about income and sign.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The amount sent is based on the patient’s medical needs per treatment.
Refills	A new prescription is faxed to the company by the doctor for every months. After 3 months a Recertification Form is faxed to the doctor to be filled out and faxed back. After 6 months a new application is needed.
Limit	Indefinitely

62. Encourage Foundation

Pharmaceutical Company	Wyeth & Amgen
Program Name	.
Program Address	C/O Intele Center Foundation PO Box 4133 Gaithersburg, MD 20885-4133
Medicines On Program	Enbrel
Phone Number	800-376-2580
Guidelines and Notes	If the patient states that they cannot afford the medication, they should be encouraged to call the program or just apply. The program will provide case management — trying to find altnerate resources — for patients who don’t meet their guidelines.
Initiating Enrollment	Staff will screen patient over the phone and if they seem to qualify, application will be sent to the patient, which is patient specific. Once application is complete mail or fax it back, they will review the information. If the patient qualifies then a prescription form is sent to the doctor.
Health Provider’s Role	The doctor fills out the prescription form and mails that to the company.
Patient’s Role	The patient must fill out the initial application, sign and attach proof or income (must be 1040 if filed taxes, if not a noterizied statement of income.)
How Dispensed	Medications are to the patient’s house unless the patient requests different.
Amount Dispensed	Patient is sent one month supply for 4 months, then 2 month supply for 4 months, and after that 3 month supply sent at a time.
Refills	The refills are sent out automatically, but the company calls to set up a delivery time. The patient is first enrolled for 4 months, then the doctor needs to sign a new prescription form. After 8 months the doctor needs to sign another prescription form. The patient only needs to fill out a new application once a year.
Limit	Indefinitely.

63. Endo Pharmaceuticals, Inc.

Pharmaceutical Company	Endo Pharmaceuticals, Inc.
Program Name	Endo Pharmaceuticals, Inc.
Program Address	PO Box 430 Hackettstown, NJ 07840
Medicines On Program	Lidoderm, Moban, Symmetrel
Phone Number	800-319-4032
Guidelines and Notes	Patient’s eligibility is based on income and lack of prescription benefits.
Initiating Enrollment	The doctor’s office must fill out an application on www.rxhope.com (Need a DEA number to be given access to the application.) Or the doctor’s office can call for an application to be faxed out.
Health Provider’s Role	The doctor must fill out the application which included medical information, insurance information and income information of the patient.
Patient’s Role	Provide the needed information to the doctor.
How Dispensed	The medication is sent to the doctor’s office
Amount Dispensed	Lidoberm is sent in a two month supply, Moban and Symmetrel are sent in a three month supply.
Refills	For each refill a new application is needed.
Limit	Unclear.

64. ESP Pharma Patient Assistance Program

Pharmaceutical Company	ESP Pharma
Program Name	ESP Pharma Patient Assistance Program
Program Address	PO Box 430 Hackettstown, NJ 07840
Medicines On Program	Declomycin 150mg, Declomycin 300mg, Ismo 20mg, Sectral 200mg, Sectral 400mg, Tenex 1mg, Tenex 2mg
Phone Number	800-319-4031
Guidelines and Notes	Patient’s income must be at or below 200% of the Federal Poverty Level and have no prescription insurance.
Initiating Enrollment	Call the above number and a copy of the application will be faxed out. The completed application can be faxed back to the company.
Health Provider’s Role	The doctor must fill out and sign one section of the application.
Patient’s Role	The patient must fill out and sign two sections of the application.
How Dispensed	The medication is sent to the physican’s office.
Amount Dispensed	Two bottles of medication are sent out.
Refills	To get a refill, send in a new application.
Limit	Indefinitely.

65. Ethyol Protect Program

Pharmaceutical Company	Medimmune, Inc.
Program Name	Ethyol Protect Program
Program Address	PO Box 222197 Charlotte NC 28222-2197
Medicines On Program	Ethyol, Neutrexin 200mg/vil, Neutrexin 25mg/vil
Phone Number	800-887-2467
Guidelines and Notes	This program mostly deals with Ethyol, but also has an application for NeuTrexin. There are two programs with the same application. One is The Insurance Patient Program which is a safety net for physicians if the patient’s insurance denies the claim. It also acts a benefits verification program. If the patient is denied coverage and the decision is appealed and still holds up, the company will send replacement medication to the phyisican’s office. The Second program is for uninsured patients and provides medication to patients who met their requirements.
Initiating Enrollment	Anyone can call for an application, and it will be faxed out. Blank applications can be copied. The application can be faxed back.
Health Provider’s Role	The physician must provide basic information and sign a Physician or Provider Site Agreement. (Once this form is filled out for the site it doesn’t have to be filled out for other patients.)
Patient’s Role	Patient must provide information about insurance and/or financial information including total household income. Patient must also sign the application and the Patient Consent Form.
How Dispensed	Medication is sent to the phyisician’s office.
Amount Dispensed	For Ethyol- up to 15 vials. For NeuTrexin- one cycle.
Refills	Sent with the medication is a refill form that the doctor must fill out and attach a prescription to for refills. After a year a whole new application is needed.
Limit	Indefinitely

66. Ferndale Laboratories, Inc.

Pharmaceutical Company	Ferndale Laboratories, Inc.
Program Name	Ferndale Laboratories, Inc.
Program Address	Customer Services 780 West Eight Mile Rd. Ferndale, MI 48220
Medicines On Program	Analpram, LMX 4, LMX5, Locoid, Pramosone
Phone Number	800-621-6003, ext 442
Guidelines and Notes	The patient must be at or below the Federal Poverty Guidelines and US citizen with no prescription coverage.
Initiating Enrollment	Anyone can call to start the process. The person will need basic patient and doctor information. The company will call the doctor’s office to confirm the information and get a prescription.
Health Provider’s Role	The doctor will have to provide a prescription.
Patient’s Role	The patient will have to provide proof of income.
How Dispensed	All meds are sent to the doctor’s office except for LMX which can be sent to the patient’s home.
Amount Dispensed	It varies according to the prescription.
Refills	Doctor or patient calls for a refill. After 6 months the process must start over.
Limit	Indefinitely

67. Financial Assistance Program for Abelcet

Pharmaceutical Company	Enzon
Program Name	Financial Assistance Program for Abelcet
Program Address	750 The City Drive, Suite 210 Orange, CA 92868
Medicines On Program	Abelcet
Application	Contact program for application
Guidelines and Notes	Patient must have minimal resources and no insurance coverage for Abelcet, and be unable to afford the drug. Company encourages physicians to administer the drug and then file with them for reimbursement rather than wait for approval, given the critical indications for use of the drug. Eligibility is determined based on medical and financial factors. Patient must be getting Abelcet from hospital, physician or home health care company for a medically appropriate application.
Initiating Enrollment	Anyone can call for an information packet and it will be mailed to doctor’s office. The blank application cannot be copied. The completed application can be faxed back but the originial must be mailed in.
Health Provider’s Role	Physicians complete, sign, then mail or fax the form. If a hospital is treating the patient then the hospital submits a consent form. Proof of patient diagnosis must be attached to application.
Patient’s Role	The patient must fill out a section, including information about gross income.
How Dispensed	The drug is sent directly to the dispensing pharmacy approximately 48 hours later
Amount Dispensed	For reimbursment: As much as was used. For patient assistance program: a 30 day supply.
Refills	The provider must call the company to reapply and provide documents that more medication is needed.
Limit	Indefinitely

68. First Horizon Patient Assistance Program

Pharmaceutical Company	First Horizon Pharmaceutcical Corp.
Program Name	First Horizon Patient Assistance Program
Program Address	PO Box 66552 St Louis MO, 63166-6552
Medicines On Program	Cognex, Nitrolingual Pumpspray, Ponstel, Robinul, Robinul Forte, Sular
Phone Number	800-869-4514
Guidelines and Notes	Patient must be a US resident and have an income below Federal Poverty Guidelines or demonstrates that buying the medication will cause financial hardship.
Initiating Enrollment	The patient or the provider can call for an application. If the patient calls it will be mailed to the patient’s house. If the provider calls the application will be faxed to the office. The blank application be copied. Completed application must be mailed.
Health Provider’s Role	Doctor completes and signs a section and included a prescription. The prescription can be made out for up to 3 refills, at 90 days a fill, except for Nitrolingual.
Patient’s Role	Detailed financial and insurance information needed, as well as a signature. Proof of income is also required, 4506 Form is best.
How Dispensed	Medications sent to physician’s office within 2-3 weeks of approval.
Amount Dispensed	The medication is sent out in a 90 day supply, except for Nitrolingual which is one bottle a year.
Refills	To get a refill the patient calls the company and requests a refill. (This only works if the doctor put refillls on the prescription.) A new application must be completed annually.
Limit	Indefinitely

69. First Resource Program

Pharmaceutical Company	Pfizer, Inc.
Program Name	First Resource Program
Program Address	6900 College Blvd, Ste 1000 Overland Park, KS 66211
Medicines On Program	Aromasin, Camptosar, Ellence, Emcyt, Idamycin, Trelstar , Zinecard
Phone Number	877-744-5675
Guidelines and Notes	The patient must be a US resident in the care of a US physician and requesting the medication for cancer. The patient must also have no insurance and meet financial guidelines that are not disclosed.
Initiating Enrollment	For Aromasin and Emcyt the patient can start the process. The entire application process is done over the phone. For the other meidcations the doctor or doctor’s office should call the start the process, then a patient specific application is sent out to the doctor’s office. The completed application can be faxed in, but also must be mailed in.
Health Provider’s Role	The provider must fill out a section and sign the application.
Patient’s Role	The patient must fill out section, sign the application, and provide proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A 30 day supply is sent out.
Refills	There a form that the doctor needs to fax in each month to get a refill. Once a year a new application with documentation is needed.
Limit	Indefinitely

70. Forest Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	Forest Pharmaceuticals, Inc
Program Name	Forest Pharmaceuticals Patient Assistance Program
Program Address	13600 Shoreline Drive St. Louis MO 63045
Medicines On Program	Aerobid Inhaler, 7 gm canister, Aerobid-M Inhaler, 7 gm canister, Aerochamber, Aerochamber with Mask, Armour Thyroid Tablets 1 gr, Armour Thyroid Tablets 1.5 gr, Armour Thyroid Tablets 1/2 gr, Armour Thyroid Tablets 1/4 gr, Armour Thyroid Tablets 2 gr, Armour Thyroid Tablets 3 gr, Armour Thyroid Tablets 4 gr, Armour Thyroid Tablets 5 gr, Celexa tablets 10 mcg, Celexa tablets 20 mcg, Celexa tablets 40 mcg, Kay Ciel Powder Packets, Levothroid Tablets 100 mcg, Levothroid Tablets 112 mcg, Levothroid Tablets 125 mcg, Levothroid Tablets 137mcg, Levothroid Tablets 150 mcg, Levothroid Tablets 175 mcg, Levothroid Tablets 200 mcg, Levothroid Tablets 25 mcg, Levothroid Tablets 300mcg, Levothroid Tablets 50 mcg, Levothroid Tablets 75 mcg, Levothroid Tablets 88 mcg, Lexapro Tablets 10 mg, Lexapro Tablets 20 mg, Tessalon Perles 100 mg, Tessalon Perles 200 mg, Theochron Tablets 100 mg, Theochron Tablets 200 mg, Theochron Tablets 300 mg, Thyrolar Tablets 1, Thyrolar Tablets 1/2, Thyrolar Tablets 1/4, Thyrolar Tablets 2, Thyrolar Tablets 3, Tiazac Capsules 120 mg, Tiazac Capsules 180 mg, Tiazac Capsules 240 mg, Tiazac Capsules 300 mg, Tiazac Capsules 360 mg, Tiazac Capsules 420 mg
Phone Number	800-851-0758
Guidelines and Notes	The patient must not be able to afford the medication and qualify under guidelines that the company does not release. It is important that the address on the prescription matches the mailing address on the applicatoin. If this is not the case please attach letterhead or buisness card to verify the delivery address. The current application list Esgic, but it is no longer covered on the program.
Initiating Enrollment	Anyone can call to get an application, it will be faxed out. The blank application can also be copied. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section of the application, sign and attach a prescription.
Patient’s Role	The patient must fill out a section and sign. The patient may be requested to show proof of income.
How Dispensed	The medication is sent directly to the doctor’s office.
Amount Dispensed	The medication is sent out in a three month supply.
Refills	Each time the patient needs medication; a new application and prescription must be mailed to the company.
Limit	Indefinitely

71. Forest Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	Forest Pharmaceuticals:Namenda
Program Name	Forest Pharmaceuticals Patient Assistance Program
Program Address	13600 Shoreline Drive St Louis, MO 63045
Medicines On Program	Namenda Tablet, 10 mg, Namenda Tablet, 5 mg, Namenda Titration Pak
Phone Number	800-851-0758
Guidelines and Notes	The patient must not be able to afford the medication and qualify under guidelines that the company does not release. It is important that the address on the prescription matches the mailing address on the applicatoin. If this is not the case please attach letterhead or buisness card to verify the delivery address.
Initiating Enrollment	Anyone can call to get an application, it will be faxed out. The blank application can also be copied. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section of the application, sign and attach a prescription.
Patient’s Role	The patient must fill out a section and sign. The patient may be requested to show proof of income.
How Dispensed	The medication is sent directly to the doctor’s office.
Amount Dispensed	The medication is sent out in a three month supply.
Refills	Each time the patient needs medication; a new application and prescription must be mailed to the company.
Limit	Indefinitely

72. Fujisawa Patient Assistance Program

Pharmaceutical Company	Fujisawa Healthcare, Inc.
Program Name	Fujisawa Patient Assistance Program
Program Address	PO Box 221644 Chantilly, VA 20153-1644
Medicines On Program	Adenocard Injection , Adenoscan , AmBisome, Aristocort A Cream, Aristocort A Ointment , Aristocort A Tablet 4mg
Phone Number	800-477-6472
Guidelines and Notes	The patient must be a US resident and meet financial and insurance guidelines that are not disclosed.
Initiating Enrollment	Healthcare provider or patient must call for a pre-screening and will need patient’s income and insurance information and some kind of proof of income to fax them. The application is patient specific and is sent to the provider’s office. The completed application must be mailed back.
Health Provider’s Role	The provider must fill out a section and sign the application.
Patient’s Role	The patient needs to provide proof of income but doesn’t need to sign the application.
How Dispensed	The medication is sent via UPS or FedEx to the provider’s office.
Amount Dispensed	Depends on availability of medication.
Refills	A new application is needed, if more medication is needed.
Limit	Indefinite.

73. Fuzeon Reimbursment Assistance Program

Pharmaceutical Company	Roche Pharmaceuticals
Program Name	Fuzeon Reimbursment Assistance Program
Program Address	PO Box 221769 Charlotte NC, 28222
Medicines On Program	Fuzeon
Phone Number	866.694.6670
Guidelines and Notes	The patient must enroll in The Progressive Distrubution Program (PDP) first, There is a application for this that is completed by the doctor and patient. On this application is a question about insurance coverage. If the patient is in need, then the patient is transferred over to the Reimbursement Assistance Program. First the program tries to find alternative coverage. If no alternative coverage is found, then another application is sent out to the doctor’s office.
Initiating Enrollment	The doctor must call to get an enrollment application for PDP. If the patient is in need to company will contact the doctor.
Health Provider’s Role	The doctor needs to fill out a section of the application and sign it.
Patient’s Role	The patient needs to fill out a section, sign the application and attach proof of income.
How Dispensed	The medication is sent either to the patient’s home or doctor’s office.
Amount Dispensed	The medication is sent in a one month kit at a time.
Refills	Shipments are sent out by the company for 6 months. The company will contact the patient when the six months is up and send a new application.
Limit	Indefinitely

74. Gabitril Patient Assistance Program

Pharmaceutical Company	Cephalon, Inc.
Program Name	Gabitril Patient Assistance Program
Program Address	PO Box 430 Hackettstown, NJ 07840
Medicines On Program	Gabitril, 12mg, Gabitril, 16mg, Gabitril, 2mg, Gabitril, 4mg
Phone Number	800-511-2120
Guidelines and Notes	The patient must be a US citizen, with an income equal or less than $17,960 for a family of one, and $24,240 for a family of two.
Initiating Enrollment	Someone from the doctor’s office should call for an application, it will be faxed out. The blank application can be photocopied.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	Patient needs to attach proof of income (list on application) and fill out a section and sign.
How Dispensed	Coupons are sent to the patient. These coupons are taken with a prescription to a pharmacy for medication.
Amount Dispensed	The coupons are good for a 90 days supply.
Refills	After 3 months, company automatically sends another coupon out. if the coupons do not arrive, the patient can call for some to be sent. A new application is needed after one year, with new proof of income.
Limit	Indefinitely

75. Galderma Laboratories Patient Assitance Program

Pharmaceutical Company	Galderma Laboratories
Program Name	Galderma Laboratories Patient Assitance Program
Program Address	14501 North Freeway Fort Worth TX 76177
Medicines On Program	Capex Shampoo Topical Shampoo 0.01%, Differin Gel 0.1%, MetroGel Topical Gel 0.75%, MetroLotion Topical Lotion 0.75%, Rozex Topical 0.75%, TriLuma Cream 30 gram
Phone Number	866-730-5074
Guidelines and Notes	Any patient who, in the judgement of the physician or dermatologist, is in need of assistance and who doesn’t qualify for state or federal assistance can apply. Patient cannot have any prescription insurance.
Initiating Enrollment	The patient or the doctor can call to get an application faxed to the doctor’s office. Completed applicaiton and prescription should be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section, sign and attach a prescription.
Patient’s Role	The patient needs to provide the needed information to the doctor (minimal information.) The patient does not need to sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	One tube of the requested medication is sent at one time. (Approximately 3-4 weeks)
Refills	For refills a new application is needed with the ‘repeat request’ box checked on the application.
Limit	Unspecified

76. Gammassist Program

Pharmaceutical Company	Baxter Healthcare Corporation
Program Name	Gammassist Program
Program Address	750 The City Drive, Ste 210 Orange, CA 92868-4940
Medicines On Program	Gammagard
Phone Number	1-800-888-4502
Guidelines and Notes	This is a safety net program for people currently insured and on Gammagaurd. Once enrolled, every quarter a coupon is sent to the patient, with a limit at 12 coupons. If, after the first year, the patient loses their insurance then the coupons can be redeemed (up to three coupons a year.) for Gammagaurd.
Initiating Enrollment	The patient can go to the website www.immunedisease.com or call the above number to get an application.
Health Provider’s Role	The doctor doesn’t need to do anything for this program.
Patient’s Role	The patient needs to give basic information.
How Dispensed	The coupon is sent to the patient’s home. When coupons are redeemed the patient needs to send the coupon back to the company.
Amount Dispensed	The coupon is based on usage up to 150 grams.
Refills	Not Applicable
Limit	Not Applicable

77. Gemzar Patient Assitance Program

Pharmaceutical Company	Eli Lilly & Company
Program Name	Gemzar Patient Assitance Program
Program Address	Address not needed; all information is exchanged with program via fax.
Medicines On Program	Gemzar
Phone Number	888-443-6927, #1
Guidelines and Notes	They have a reimbursement program for patients with insurance who have been denied coverage for Gemzar and a program for patients with no insurance. Patients with no insurance must first meet their income guidelines which they will not disclose. And the patient must be still taking the medication or about to start taking the medication. Also, to apply for either program, patient must currently be in outpatient treatment.
Initiating Enrollment	Provider must call. They screen for eligibility over the phone and then fax the patient’s application to the provider. The completed application should be faxed back.
Health Provider’s Role	Doctor completes and signs a section of the application. If applying for a patient who’s been denied insurance coverage, doctor submits denial letters and program assists with appeals.
Patient’s Role	The patient must fill out a section of the application and answer fanancial and insurance questions and sign the application. The patient must also provide proof of income.
How Dispensed	The company sends medication to provider’s office.
Amount Dispensed	Depends on dosing regimen.
Refills	For each date of service the doctor’s office must send in the dose tracking form and the flow sheet to get another dosage.
Limit	Indefinitely

78. Genetech Access To Care Foundation (Growth Hormones)

Pharmaceutical Company	Genentech, Inc.
Program Name
Program Address	1 DNA Way, Mail Stop 210 So. San Francisco CA 94080
Medicines On Program	Nutropin, Nutropin AQ, Nutropin Depot, Protropin
Phone Number	800-879-4747
Guidelines and Notes	The patient must have no insurance, or be under insured for the medication. There are two Statements of Medical Necessity and Authorization Forms, one for adults and one for children.
Initiating Enrollment	The doctor must call for a Statement of Medical Necessity and Patient Authorization Form. It can also be downloaded from www.spoconline.com The doctor must fax the completed Statement and Authorization Form to the company who will decide if the patient is eligible. If the patient is eligible, than an applicaiton is sent to the patient.
Health Provider’s Role	The doctor only needs to fill out the information on the Statement of Medical Necessity, it has a prescription section, and a place to sign. The first time the doctor enrolls a patient, the doctor must also enroll, using the Physician Profile (available on www.spoconline.com).
Patient’s Role	The patient has to sign the Patient Authorization Form and fill out the application that is sent to her/his home.
How Dispensed	The medication is sent to either the patient’s home or the doctor’s office.
Amount Dispensed	Starts with a 30 day supply. After that up to a ninty day supply can be sent.
Refills	The patient needs to call two weeks before they run out to get a refill. Every year in May a new application is needed.
Limit	Unspecified.

79. Genentech Access to Care (Activase, TNKase & Cathflo)

Pharmaceutical Company	Genentech, Inc.
Program Name	Genentech Access to Care (Activase, TNKase & Cathflo)
Program Address	1 DNA Way, Mail Stop 210 So. San Francisco CA 94080
Medicines On Program	Activase, Cathflo 2 mg, TNKase
Phone Number	800-530-3083, Opt 1
Guidelines and Notes	The patient must have no insurance, and have a family income of less than $30,00. The diagnosis must be FDA approved, except for Cathflo. This is a drug replacement program.
Initiating Enrollment	The facility, doctor or hospital calls to get an application which is faxed out. The completed application can be faxed back.
Health Provider’s Role	Doctor needs to complete and sign a section of the application.
Patient’s Role	The patient needs to give the provider information, but does not need to sign form.
How Dispensed	The medication is sent to the hospital or facility.
Amount Dispensed	The amount of medication depends on what is used for the patient. In case of large amounts the company may require proof of use.
Refills	Not applicable, since this is a replacement.
Limit	Unspecified.

80. Genentech Access To Care Foundation (Oncology Medications)

Pharmaceutical Company	Genentech, Inc.
Program Name	Genentech Access To Care Foundation (Oncology Medications)
Program Address	1 DNA Way, Mail Stop 210 So. San Francisco CA 94080
Medicines On Program	Herceptin, Rituxan
Phone Number	800-530-3083, opt 1
Guidelines and Notes	The patient must have no insurance, and have a family income of less than $75,000. The diagnosis must be FDA approved, if the diagnosis is not FDA approved, speak to the company. This is a drug replacement program.
Initiating Enrollment	The provider’s office can call to get an application faxed to the office or anyone can go online www.spoconline.com. The completed application should be faxed back.
Health Provider’s Role	Doctor needs to complete and sign a section of the application.
Patient’s Role	The patient needs to provide information and sign the application.
How Dispensed	The medication is sent to the doctor’s office or the hopital.
Amount Dispensed	The amount of medication depends on what is used for the patient.
Refills	Not applicable, since this is a replacement.
Limit	Unspecified.

81. Genentech Access to Care (Raptiva)

Pharmaceutical Company	Genentech, Inc.
Program Name	Genentech Access to Care (Raptiva)
Program Address	Not Applicable
Medicines On Program	Raptiva
Phone Number	877-727-8482
Guidelines and Notes	The patient must have no insurance, or be under insured for the medication.
Initiating Enrollment	The doctor must call for a Statement of Medical Necessity and Patient Authorization Form. It can also be downloaded from www.spoconline.com The doctor must fax the completed Statement and Authorization Form to the company who will decide if the patient is eligible. If the patient is eligible, than an applicaiton is sent to the patient.
Health Provider’s Role	The doctor only needs to fill out the information on the Statement of Medical Necessity, it has a prescription section, and a place to sign. The first time the doctor enrolls a patient, the doctor must also enroll, using the Physician Profile (available on www.spoconline.com).
Patient’s Role	The patient has to sign the Patient Authorization Form and fill out the application that is sent to her/his home.
How Dispensed	The medication is sent to either the patient’s home or the doctor’s office.
Amount Dispensed	Starts with a 30 day supply. After that up to a ninty day supply can be sent.
Refills	The patient needs to call two weeks before they run out to get a refill. Every year in May a new application is needed.
Limit	Unspecified.

82. Genentech Access to Care (Xolair)

Pharmaceutical Company	Genentech, Inc.
Program Name	Genentech Access to Care (Xolair)
Program Address	Not Applicable
Medicines On Program	Xolair
Phone Number	800.704.6614
Guidelines and Notes	The patient must have no insurance, and meet financial guidelines that are not disclosed. The diagnosis must be FDA approved, if the diagnosis is not FDA approved, speak to the company.
Initiating Enrollment	The doctor must call for a Statement of Medical Necessity and Patient Authorization Form. It can also be downloaded from www.spoconline.com The doctor must fax the completed Statement and Authorization to one of the following speciality pharmacy companies who will send it on to Genentech. 1) Care Market: (f) 800-323-2445 (p) 800-237-2767 2) Curascript (f) 888-773-78386 (p) 888-281-5464 3) NovaFactor (f) 866-531-1025 (p) 866-839-2162 4) Option Care (f) 888-570-4700 (p) 888-282-5166 5) Priority Healthcare (f) 866-269-3113 (p) 866-757-3929 If the patient is eligible for the program then an application is sent to the patient.
Health Provider’s Role	The doctor only needs to fill out the information on the Statement of Medical Necessity, it has a prescription section, and a place to sign. The first time the doctor enrolls a patient, the doctor must also enroll, using the Physician Profile (available on www.spoconline.com).
Patient’s Role	The patient has to sign the Patient Authorization Form and fill out the application that is sent to her/his home.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	Usually a one month treatment is sent at one time.
Refills	The doctor’s office call for refills. Once a year a new application is needed.
Limit	Indefinitely.

83. Genentech Endowment for Cystic Fibrosis

Pharmaceutical Company	Genentech, Inc.
Program Name	Genentech Endowment for Cystic Fibrosis
Program Address	PO Box 222157 Charlotte, NC 28222-2157
Medicines On Program	Pulmozyme
Phone Number	800-297-5557
Guidelines and Notes	They encourage patients to call them while completing the application. They can be reached between 9 and 5pm EST. Patient must have Cystic Fibrosis. Patient and physician fill out application. Patient must either have no insurance or not be able to afford the co-payments. The company looks at out of pocket medical expenses, household income, but the guidelines are not disclosed. Program may provide full or partial assistance.
Initiating Enrollment	Anyone can call for application or get one from www.genentechcfendowment.org. Completed applications and documentation can be mailed or faxed. Both patients and physicians will be notified in writing about eligibility.
Health Provider’s Role	The doctor must complete a section and sign a page of the application.
Patient’s Role	Patient (or guardian) signature required. Income and insurance information required. Copy of most recent tax return, and denials for public assistance (if appropriate) or insurance denial for Pulmozyme needed.
How Dispensed	Once accepted into the program, s/he is sent three vouchers at once, one voucher per month to be taken to the pharmacy.
Amount Dispensed	There is no set limit or amount of medication sent.
Refills	Every three months a new set of vouchers is sent out. After a year a whole new application is needed.
Limit	Indefinitely

84. Geodon Patient Assistance Program

Pharmaceutical Company	Pfizer, Inc.
Program Name	Geodon Patient Assistance Program
Program Address	PO Box 52119 Phoenix, AZ 85072
Medicines On Program	Geodon 20mg, Geodon 40mg, Geodon 60mg, Geodon 80mg
Phone Number	866-443-6366
Guidelines and Notes	The patient must be a US resident, have no prescription coverage, or have reached their limit. The patient must also fall below income guildelines that they don’t release.
Initiating Enrollment	The doctor or social worker should call to get an application, which will be faxed out. The blank application can be photocopied. The completed application can be faxed or mailed back to the company. Provider is notified if the patient is accepted.
Health Provider’s Role	Provider completes prescriber information and checks off dose required.
Patient’s Role	The patient must fill out sections on insurance, income and sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	Upon acceptance, a 30 day supply is sent out while a case manager tries to find another payer source. After the initial 30 day supply, and if there is no alternative source another 60 day supply is sent out.
Refills	A form will be sent to the doctor’s office that is required every 90 days for refills. After a year a whole new application is needed.
Limit	Unspecified

85. Gilead Commitment to Access

Pharmaceutical Company	Gilead Sciences
Program Name	Gilead Commitment to Access
Program Address	PO Box 221887 Charlotte, NC 28222-1887
Medicines On Program	DaunoXome, Emtriva, Hepsera, Viread, Vistide
Phone Number	800-226-2056
Fax Number	800-216-6857
Initiating Enrollment	Anyone can call to get an application, which can be faxed or mailed out. The blank application can be copied. The completed application can be faxed or mailed back to the company.
Health Provider’s Role	The doctor must fill out a section and attach a prescription.
Patient’s Role	The patient must fill out a section of the application and sign. The company may request documentation.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The medication is sent in a one month supply.
Refills	After 90 days a Verfication Letter is sent to both the doctor and the patient, those forms are sent back in with a new prescription to get another 90 days worth. After one year a new application is needed.
Limit	Not specified.

86. Glaxo-SmithKline Commitment to Access

Pharmaceutical Company	GlaxoSmithKline
Program Name	Glaxo-SmithKline Commitment to Access
Program Address	PO Box 29038 Phoenix, AZ 85038-9038
Medicines On Program	Bexxar, Hycamptin for injection, Leukeran 2mg (Sugar Coated Tablets), Myleran 2-mg Scored Tablets, Navelbine Injection, Tabloid 40-mg Scored Tablet, Zofran Injection , Zofran Injection Premixed, Zofran Oral Solution, Zofran Orally Disintegrating Tablets 4 mg, Zofran Orally Disintegrating Tablets 8 mg, Zofran Tablets 24mg, Zofran Tablets 4mg, Zofran Tablets 8 mg
Phone Number	1-866-265-6491
Guidelines and Notes	The patient must be a US resident, have a household income not more that 350% of the Federal Poverty Level and have no prescription insurance. GlaxoSmithKline requests that an “Advocate” be the contact person for the patient throughout the entire process. The advocate can be any healthcare worker involved in the patient’s care (i.e., doctor, nurse, social worker, or someone in the healthcare office or facility).
Initiating Enrollment	An advocate must call for an application, which will be faxed or mailed out with a patient number on the application. The advocate can also start the enrollment process online at commitmenttoaccess.gsk.com. The application cannot be copied. After the patient and advocate fill out the application, the advocate must call the company to complete the enrollment process.
Health Provider’s Role	The doctor must complete a section, attach a prescription and sign the application. If the appliaction is accepted then the prescription must be faxed to 1-800-750-9832, please indicate “Attention: Direct Ship Specialist.”
Patient’s Role	The patient’s role is to complete a section of the application that asks questions about insurance and monthly gross income. When completed, the patient will sign the application and attach proof of income.
How Dispensed	Sends medicine to doctor’s office within a week of approval.
Amount Dispensed	The medication will be sent in a 30 day supply.
Refills	To initiate the next 30-day shipment, the advocate must call five to seven business days before the medication runs out. Every year, the patient and advocate need to complete a new application. GlaxoSmithKline will send a reminder letter whenever they need new information or documentation.
Limit	Indefinite

87. GlaxoSmithKline Bridges To Access

Pharmaceutical Company	GlaxoSmithKline
Program Name	GlaxoSmithKline Bridges To Access
Program Address	PO Box 29038 Phoenix, Az 85038
Medicines On Program	Aclovate cream .05%, Aclovate ointment .05%, Advair Diskus 100/50, Advair Diskus 250/50, Advair Diskus 500/50, Agenerase Capsules 150 mg, Agenerase Capsules 50 mg, Agenerase Oral Solution, Amerge Tablets 1mg, Amerge Tablets 2.5mg, Amoxil Capsules 500mg, Amoxil Chewable Tablets 200mg, Amoxil Chewable Tablets 250 mg, Amoxil For Oral Suspension 250mg/5ml, Amoxil For Oral Suspension 400mg/5ml, Amoxil Powder 50mg/ml, Amoxil Powder for Oral Suspension 125mg/5ml, Amoxil Powder for Oral Suspension 200mg/5ml, Amoxil Tablets 400 mg, Amoxil Tablets 500 mg, Amoxil Tablets 875 mg, Augmentin ES-60O, Augmentin Oral Suspension -Chewable Tablets, Augmentin Powder for Oral Suspension 200mg/5ml , Augmentin Powder for Oral Suspension 250mg/5 ml, Augmentin Tablets, Augmentin XR, Avandia Tablets 2mg, Avandia Tablets 4mg, Avandia Tablets 8mg, Avanvamet Tablets, Avodart, Bactroban Creme, Bactroban Ointment, Beconase AQ Nasal Spray .042%, Ceftin Oral Suspension 125mg, Ceftin Oral Suspension 125mg/5ml, Ceftin Oral Suspension 250mg/5ml, Ceftin Tablets 125mg, Ceftin Tablets 250mg, Ceftin Tablets 300mg, Ceftin Tablets 500mg, Ceftin Tablets 601.44 mg, Combivir, Coreg Tablets 12.5mg, Coreg Tablets 25mg, Coreg Tablets 3.125mg, Coreg Tablets 6.25mg, Cultivate Cream .05%, Cultivate Ointment .005%, Daraprim 25 mg Scored Tablets, Dexedrine Spansule Capsules, Dexedrine Tablets, Dyazide Capsules 25mg/37.5mg, Epivir Oral Suspension, Epivir Tablets 150mg, Epivir Tablets 300mg, Epivir-HBV Oral Suspension, Epivir-HBV Tablets, Eskalith CR Capsules 300 mg, Eskalith CR Tablets 450 mg, Flonase Nasal Spray 50 mcg., Flovent 110 mcg, Flovent 220 mcg, Flovent 44 mcg, Flovent Rotadisk 100 mcg, Flovent Rotadisk 250 mcg, Flovent Rotadisk 50 mcg, Fortaz Injection 1gm/vil, Fortaz Injection 2gm/vil, Fortaz Injection 500mg/vil, Fortaz Injection 6gm/vil, Imitrex injectable, Imitrex nasal spray 20mg/unit, Imitrex nasal spray 5mg/unit, Imitrex tablets 100 mg, Imitrex tablets 25 mg, Imitrex tablets 50 mg, Lamictal Chewable Dispersible Tablets 25mg, Lamictal Chewable Dispersible Tablets 2mg, Lamictal Chewable Dispersible Tablets 5 mg, Lamictal Tablets 100 mg, Lamictal Tablets 200 mg, Lamictal Tablets 25 mg, Lanoxicaps 100 mcg Imprint B2C (yellow), Lanoxicaps 200 mcg Imprint C2C (Green), Lanoxicaps 50 mcg Imprint A2C (Red), Lanoxin Elixir Pediatric 50 mcg, Lanoxin Tablets, Lotronex, Malarone Pedatric Tablets, Malarone Tablets 250mg;100mg, Malarone Tablets 62.5mg;25mg, Mepron, Oxistat Cream 1%, Oxistat Lotion 1%, Parnate Tablets 10mg, Paxil CR 12.5 mg, Paxil CR 37.5 mg, Paxil Oral Suspension, Paxil Tablets 10 mg, Paxil Tablets 20 mg, Paxil Tablets 40 mg, Relafen 500mg , Relafen 750mg , Relenza Powder for Inhalation, Requip 0.25mg, Requip 0.5 mg, Requip 1 mg, Requip 2 mg, Requip 3 mg, Requip 4 mg, Requip 5 mg, Retrovir Capsules, Retrovir Syrup, Retrovir Tablets, Serevent Diskus Powder for Inhalation 50mcg, Tagamet Tablets 300mg, Tagamet Tablets 400mg, Tagamet Tablets 800mg, Temovate Cream , Temovate E Emollient, Temovate Emollient, Temovate Gel, Temovate Ointment, Temovate Scalp Application, Timentin, Timentin Injection, Trizivir, Valtrex Capsules, Ventolin HFA, Wellbutrin SR, Wellbutrin Tablets, Wellbutrin XL Tablets, Zantac 150 EFFERdose Tablets, Zantac 150 tablets, Zantac 300 tablets, Zantac Injection , Zantac Injection Premixed, Zantac Syrup, Ziagen oral solution, Ziagen tablets, Zinacef, Zovirax capsules, Zovirax suspension, Zovirax tablets, Zyban SR Tablets
Phone Number	866-728-4368
Guidelines and Notes	The patient must be a US resident, have a household income not more that 250% of the Federal Poverty Level for a multiple income household and not more than $25,000 for a single income household. The patient also can not have any prescription insurance. The company requests that an ‘Advocate’ be the contact person for the patient, throughout the entire process. The advocate can be any healthcare worker invovled in the patient’s care. (Phyisician, nurse, social worker or some in the healthcare office or facility.)
Initiating Enrollment	The advocate calls for an application and it will be faxed or mailed out with a patient ID number. Or the enrollment process may be started on line at bridgestoaccess.gsk.com. After the application is filled out the advocate must call the company to start the enrollment process. If the patient is accepted during the enrollment phone call the coupon attached to the form is activated for a 60 day supply of medication with a small co-pay. The completed applicatin must also be mailed in.
Health Provider’s Role	Doctor completes, and signs the application. A prescription for 3 90 day refills. The advocate must also complete a section and sign the form.
Patient’s Role	The patient must fill out a detailed section on financial and income information. The patient must also provide proof of income and insurance information.
How Dispensed	After the initial 60 day supply that is recieved using the coupon, the medication is shipped to the patient’s house. The following drugs must be picked up at a pharmacy: Relenza, Dexedrine, and Lotronex.
Amount Dispensed	After the initial 60 day supply, the medication is given out in a 90 day supply.
Refills	To get the 90 day refill the patient must call 1-866-PATIENT to request the next shipment. After six months the Advocate will recieve a form to reauthorize the patient for another six months. After one year a Re-enrollment form is sent to the advocate to re-enrolll the patient for another year.
Limit	Indefinitely

88. Glenwood Compassionate Drug Program

Pharmaceutical Company	Glenwood & Western Medical
Program Name	Glenwood Compassionate Drug Program
Program Address	Glenwood LLC 111 Cedar Lane Englewood NJ, 07631
Medicines On Program	Potaba
Phone Number	800-542-0772 ext 1
Guidelines and Notes	Enrollement for this program is a case by case. The company limits to only 20 patients nationwide at any given time, but rarely have 20 people on the program. Patients must be in financial need and be willing to take what they consider the full therapeutic dosage (12 grams a day.)
Initiating Enrollment	Any health care professional can call for the application. The application can be copied. Completed applcation can be faxed back.
Health Provider’s Role	The doctor must fill out a section, sign and attach a prescription and their state license number. A personal letter is needed only if the patient does not meet the two outlined criteria. The letter needs to explain why the patient should still be eligible.
Patient’s Role	Needs to sign and fill out a section. They must also send in proof of income for all the family members.
How Dispensed	Medication is shipped to the doctor’s office.
Amount Dispensed	Medication is sent out for three months.
Refills	When the medication is running low, the doctor’s calls for refills.
Limit	Indefinetly.

89. Hectorol Patient Assistance Program

Pharmaceutical Company	Bone Care International, Inc.
Program Name	Hectorol Patient Assistance Program
Program Address	Bone Care Center 1600 Aspen Commons Middleton, WI 53562
Medicines On Program	Hectorol Capsules 2.5 mcg
Phone Number	888.389.3300
Guidelines and Notes	A patient must meet financial guidelines that are not disclosed. The patient must also be a US resident, with no medical insurance and be ineligible for government assistance. If the patient is eligble for Medicaid benefits, they must have reached their cap or not be covered for the medication.
Initiating Enrollment	Anyone can call for an application or go to the website, www.hectorol.com and applications will be automatically mailed out or faxed out. The completed application mailed or faxed back to the company.
Health Provider’s Role	The doctor must fill out a section, sign and attach a copy of their state license certificate. The perscription is built iinto the application.
Patient’s Role	The patient must fill out a section with insurance information and sign the application. The patient must also attach financial documents (SSI, W2 or IRS forms.)
How Dispensed	The medication is sent to the doctor’s office within two weeks.
Amount Dispensed	A three month supply is sent out.
Refills	For each refill a Prescription Verification Form must be filled out by the doctor and faxed back with a new prescription. All applications expire on December 31, and then a new application is needed.
Limit	Indefinitely

90. Helping Hands Program for Mead Johnson Nutritionals

Pharmaceutical Company	Mead Johnson Nutritionals
Program Name	Helping Hands Program for Mead Johnson Nutritionals
Program Address	2400 W. Lloyd Expressway Evansville, IN 47721
Medicines On Program	Enfacare AR Liplil, Enfamil Pregestimil, Nutramigen
Phone Number	800-222-9123
Guidelines and Notes	They are a division of Bristol Myers Squibb. For infants using a very specialized formulas. Baby must be under one year of age. There are many factors involved in determining eligibility for this program, which are not disclosed, but household income is an important factor.
Initiating Enrollment	Doctor calls sales representative who will determine if family qualifies for assistance. The sales rep will then contact the patient to
Health Provider’s Role	Minimal – makes call to company representative.
Patient’s Role	Let physician know they can’t afford the formula.
How Dispensed	Usually sent to family.
Amount Dispensed	Not specified.
Refills	Have provider call again. Refills are available
Limit	Unspecified

91. IVAX Patient Assistance Program for Clozapine

Pharmaceutical Company	IVAX Pharmaceuticals, Inc.
Program Name	IVAX Patient Assistance Program for Clozapine
Program Address	IVAX Patient Assistance Program for Clozapine 50 NW 176th Street Butler Building, Second Floor Miami, Florida 33169
Medicines On Program	Clozapine
Phone Number	800-507-8334
Fax Number	800-507-8334
Initiating Enrollment	Both the Registration form and the Patient Assistant Program application can be copied, and faxed out to people. Completed forms and applications can also be faxed back.
Health Provider’s Role	The physican must fill out a section and sign it. The pharmacy that the medication will sent to must also fill out a section. The pharmacy must be willing to distribute the medication at no charge.
Patient’s Role	Minimal information required, would be on-file for the Registration form.
How Dispensed	The medication is sent to the pharmacy indicated on the application.
Amount Dispensed	A 12 week supply is sent out, that is given to the patient once or twice a week.
Refills	With the medication there is Refill Form that the pharmacist fills out and sends back for refills.
Limit	Indefinitely

92. Janssen Patient Assistance Program

Pharmaceutical Company	Janssen Pharmaceutica
Program Name	Janssen Patient Assistance Program
Program Address	PO Box 221857 Charlotte NC 28222-1857
Medicines On Program	Duragesic CII, Nizoral Tablets, Reminyl Oral Solution, Reminyl Tablets, Sporanox Capsules, Sporanox Oral Solution
Phone Number	800-652-6227, option #2
Guidelines and Notes	If a patient cannot afford the drug, an application should be completed. They have financial guildelines that are not disclosed, but based on the Federal Guildelines. But there are other factors that the company takes into account.
Initiating Enrollment	Anyone can call for application. They will fax it and it can be copied. The completed application can be mailed or faxed to the company.
Health Provider’s Role	The doctor must complete a section of the application, and sign it.
Patient’s Role	The patient must provide basic information including insurance and financial information. The patient must also provide most recent tax form, if taxed were filed.
How Dispensed	The medication is sent to the doctor’s office except for Duragesic, Reminyl. These two work on a pharmacy card that is sent to the patient.
Amount Dispensed	The medications are send in a 30 day supply. The pharmacy card is good for a 30 day supply at one time.
Refills	The medication is automatically sent to the doctor’s office every month. Initial application is good for 6 months. Re-apply in same manner every 6 months.
Limit	Indefinitely

93. Kadian Patient Assistance Program

Pharmaceutical Company	Alpharma Pharmaceuticals
Program Address	PO Box 66554 St. Louis MO 63166-6554
Medicines On Program	Kadian C-II
Phone Number	866-884-5907
Application	Click here to download PDF
Guidelines and Notes	Medication is provided at no charge to needy patients. The patient no prescription coverage, US citizen, financial guidelines that are not disclosed. Make sure every space on application is either completed or marked “N/A” or “none”; incomplete applications won’t be processed. There is a five dollar montly fee to pay for the shipping.
Initiating Enrollment	Company has an automatic fax system to send faxes to the doctor’s office. The blank application can be copied. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill in a section and sign the application and attach a prescription.
Patient’s Role	The patient needs to fill out a section with detailed financial and income information. The patient also must sign the application. Every month the patient must send a $5 money order for the shipment charges.
How Dispensed	Patient will be notified of status of application. If approved, prescription is submitted and medication is shipped directly to patient.
Amount Dispensed	One month supply at a time is sent.
Refills	A new prescription and $5 money order is needed for the next month supply. Every year a new application is needed.
Limit	Patient can stay on program for up to 2 years

94. Keppra Patient Assistance Program

Pharmaceutical Company	UCB Pharma, Inc.
Program Name	Keppra Patient Assistance Program
Program Address	1950 Lake Park Drive Smyrna, GA 30080
Medicines On Program	Keppra
Phone Number	800-477-7877 x7
Guidelines and Notes	The patient must not have any prescription coverage, or be eligible for Medicaid benefits. Individual patients must not have an annual income greater than $15,000. A family with dependents must not exceed $25,000.
Initiating Enrollment	The patient or provider can call for an application, which is faxed. The blank application can be copied. The completed application must be mailed back.
Health Provider’s Role	The doctor must fill out a section of the application, sign and attach a 6 month prescription.
Patient’s Role	The patient must also fill out a section of the application and sign.
How Dispensed	To the doctor’s office. Allow 4 to 6 weeks for delivery.
Amount Dispensed	An six month supply is sent at one time. The program will not supply quantities in excess of the maximum approved daily dose (3000 mg/day.)
Refills	Every six months a new application is required.
Limit	Not specified.

95. King Kare Patient Assistance Program

Pharmaceutical Company	King Pharmaceuticals
Program Name	King Kare Patient Assistance Program
Program Address	100 18th Street Bristol, TN 37620
Medicines On Program	Altace Capsules 1.25 mg, Altace Capsules 10 mg, Altace Capsules 2.5 mg, Altace Capsules 5 mg, Anusol -HC 25 mg Suppository, Anusol- HC 2.5% Cream, Corgard 120mg, Corgard 160mg, Corgard 40mg, Corzide, Cytomel 25mcg, Cytomel 50mcg, Cytomel 5mcg, Florinef, Intal Inhaler 14.2 gm, Intal Nebulizer Solution 20mg/2 ml, Kemadrin Tablets 5 mg, Levoxyl 300mcg, Levoxyl 100 mcg, Levoxyl 112 mcg, Levoxyl 125 mcg, Levoxyl 137 mcg, Levoxyl 150 mcg, Levoxyl 175 mcg, Levoxyl 200 mcg, Levoxyl 25 mcg, Levoxyl 50 mcg, Levoxyl 88 mcg, Lorabid 200 mg Capsules, Lorabid 400 mg Capsules, Menest 2.5 mg tablets, Menest Tablets 0.3 mg, Menest Tablets 0.625 mg, PreFest 1 mg , Procanbid 1000 mg tablets, Procanbid 500 mg tablets, Proctocort 1% cream, Proctocort 30 mg suppositories, Quibron Capsules 150 mg, Quibron-T Accudose Tablets 300 mg, Quibron-T/SR Accudose Tablets 15 mg, Skelaxin, Tapazole Tablets 10mg, Tapazole Tablets 5 mg, Thalitone Tablets 15 mg, Tilade, Viroptic 1% ophthalmic solution
Phone Number	1-877-546-5332
Guidelines and Notes	This program is temporarily closed to new applications. The program may be back and running again in a few months. The patient must be a US resident, has no prescription insurance, both public or private. The patient must also meet the financial guidelines that not disclosed.
Initiating Enrollment	Anyone can call for an application but they will only fax the application to the doctor’s office. The blank application can be copied. The completed application must be mailed back. The most recent application has the date 02-27-2004. (Form #278-R01)
Health Provider’s Role	A physician must fill out a section including State License number and sign off that the patient is in need. The signature must be an original. The application has a built in prescription.
Patient’s Role	The patient must provide monthly household income and sign the application. The patient must provide proof of US citizenship if the patient has no social security number. The patient is also asked to provide proof of income.
How Dispensed	The medication is sent to the physician’s office.
Amount Dispensed	A three month supply is sent to the doctor’s office.
Refills	For another 3 month supply another application is required.
Limit	Not Applicable

96. Kos Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	Kos Pharmaceuticals
Program Name	Kos Pharmaceuticals Patient Assistance Program
Program Address	2200 N. Commerce Parkway, Ste 300 Weston, FL 33326
Medicines On Program	Advicor ER Tablets 20mg/1000mg, Advicor ER Tablets 20mg/500mg, Azmacort Inhaler, Niaspan 1000 mg, Niaspan 500 mg, Niaspan 750mg
Phone Number	1-888-206-7015, ext 2
Guidelines and Notes	The patient must not qualify for government assistance or have any third party insurance coverage. not disclosed. Assume that it will take three weeks for shipping.
Initiating Enrollment	The provider needs to fax a request to the company to get an application. The docotor’s name, fax number and telphone number are required for an application. THe blank application can be copied The completed application can be faxed or mailed back.
Health Provider’s Role	A licensed physician must fill in a section including state license number and attach a prescription up to three months.
Patient’s Role	The patient (or legal guardian) must fill out a section and sign. The patient must also attach 1040 tax form or some sort of documentation of financial support.
How Dispensed	The medication is sent to the doctor’s office, in about three weeks.
Amount Dispensed	A shipment of 3 months is sent out.
Refills	A new prescription is needed for refills. Once a year a new application is needed.
Limit	Indefinitely.

97. Ligand Assistance Program

Pharmaceutical Company	Ligand Pharmaceuticals
Program Name	Ligand Assistance Program
Program Address	PO Box 222197 Charlotte, NC 28222-2197
Medicines On Program	ONTAK 2 mL vial, Panretin Gel 60gm, Targretin capsules 75mg, Targretin Gel 60gm Tube
Phone Number	877-654-4263
Guidelines and Notes	Patient must be unable to purchase medicine and cannot have prescription coverage for the medication. The patient must meet income guildelines that are not disclosed. Once the application is received, they will make a determination of eligibility within 48 hours and notify provider.
Initiating Enrollment	Anyone can call for an application, it will faxed out to the doctor’s office. The blank application can copied. The completed application can be faxed or mailed.
Health Provider’s Role	Doctor must complete a section of the application and sign. The doctor must also attach a prescription for the medication.
Patient’s Role	Patient must fill out a section with detailed financial and insurance information needed and must sign.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The amount sent depends on the patient’s need, but usually a one month supply.
Refills	The company will fax a Verification Form to the doctor’s office and once that is filled out and returned another shipment is sent out. Once a year a whole new application is needed.
Limit	Indefinitely

98. Forteo Program

Pharmaceutical Company	Eli Lilly & Company
Program Name	Forteo Program
Program Address	Not Applicable
Medicines On Program	Forteo 3mL (or 750 msg)
Phone Number	866.436.7836
Guidelines and Notes	This program is a two step process. The first step is that the doctor needs to fill out a Insurance Verification Application and send it to the company. If the patient has no insurance or is not covered for the medication then an Enrollment Kit is sent to the patient.
Initiating Enrollment	Someone from doctor’s office calls to get an Insurance Verification Applcation. The completed application can be faxed back. This application needs patient information including: insurance and medical history. The second application is sent to the patient and must be mailed back.
Health Provider’s Role	The doctor only needs to fill out the first application.
Patient’s Role	The patient needs to fill out the second application in the Enrollment Kit. The patient will also need to attach proof of income and mail the application back.
How Dispensed	The patient is sent a prescription card that is used with a prescription at a pharmacy.
Amount Dispensed	For each refill the doctor needs to write a new prescription which the patient takes to the pharmacy with the card.
Refills	A Renewal Form is sent out for reapplication after one year.
Limit	Indefinitely

99. Lovenox Reimbursement Services and Patient Assitance Program

Pharmaceutical Company	Aventis Pharmaceuticals
Program Name	Lovenox Reimbursement Services and Patient Assitance Program
Program Address	P.O. Box 8256 Somerville NJ, 08876
Medicines On Program	Lovenox
Phone Number	888-632-8607
Guidelines and Notes	This program has both an insurance verification component and a patient assistance program but only one form. The patient must be a US resident, and cannot qualify for any prescription coverages for Lovenox, including all government programs. The patient must also have an annual income at or below $18,620 for a family of one, $24,980 for a family of 2, and $31,340 for a family of 3. The patient must also be taking Lovenox as an outpatient.
Initiating Enrollment	Anyone can call for the application and it will be faxed out. It can also be copied. Once the application is completed it can be faxed back.
Health Provider’s Role	A practitoner must fill out a section, sign a statement and attach a prescription.
Patient’s Role	Basic financial and insurance information and signature.
How Dispensed	The medication is sent to the practitioner’s office.
Amount Dispensed	The medication is sent out in a 3 month supply.
Refills	After 3 months a new application must be sent out. (Can be a copy of first application, with new signatures and dates)
Limit	Indefinitely

100. Lupron Depot Patient Assitance Program

Pharmaceutical Company	TAP Pharmaceuticals, Inc.
Program Name	Lupron Depot Patient Assitance Program
Program Address	PO Box 66586 St. Louis MO 63166-6586
Medicines On Program	Lupron 11.25 mg , Lupron 3.75 mg
Phone Number	800-830-1015, option 2
Guidelines and Notes	Patient must be at or under the Federal Poverty Guideline. The patient must have been denied Medicaid coverage and have no insurance.
Initiating Enrollment	Someone from the doctor’s office must call for the application, it will be automatically faxed out. The application can be copied. The completed application must be faxed back from the doctor’s office.
Health Provider’s Role	Doctor completes a section and signs it. The prescription is part of the application.
Patient’s Role	Before being accepted into program, patient must apply for Medicaid and have documentation that they don’t qualify. The patient must also fill out a section of the application about monthly income and insurance information. The patient must also sign the application.
How Dispensed	The company sends medicine to doctor’s office.
Amount Dispensed	A 30 day supply of the medication is sent out.
Refills	For refills, call the above number, or fax in a new application.
Limit	Lupron is only indicated for up to 6 injections per lifetime.

101. Mallinckrodt Patient Assistance Program

Pharmaceutical Company	Mallinckrodt
Program Name	Mallinckrodt Patient Assistance Program
Program Address	Pharmacy Providers of Oklahoma PO Box 18204 Oklahoma City, OK 73154
Medicines On Program	Anafranil, Pamelor Capsules , Restoril, Tofranil, Tofranil-PM
Phone Number	1-800-259-7765 X110
Guidelines and Notes	To be eligible patients must not have any prescription coverage and meet financial guidelines that are not disclosed. If accepted the patient must pay a co-pay of 60% of the cost of the medication.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. The blank application can be copied. The completed application can be faxed or mailed back.
Health Provider’s Role	Not applicable.
Patient’s Role	Patient must fill out a section about insurance, and choose a pharmacy and sign the application.
How Dispensed	The patient will get a prescription card that is taken with the prescription to the pharmacy.
Amount Dispensed	Not Applicable
Refills	The card is good for one year. Every year a new application is needed.
Limit	Not Applicable

102. Matulane Patient Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Matulane Patient Assistance Program
Program Address	C/O NORD PO Box 1968 Danbury, CT 06813-1968
Medicines On Program	Matulane
Phone Number	800.999.6673
Guidelines and Notes	Patient must have a diagnosis of Stage III or IV Hodgkin’s Disease or have another lymphoma where a phyisician feels a response is possible. Patients must also be US citizens or permanent residents. Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage.The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening, an application is sent.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section and sign the application
How Dispensed	The medication is sent to the patient.
Amount Dispensed	The amount sent is a 90 day supply.
Refills	One application will cover the course of the treatment that is prescribed by the doctor.
Limit	Indefinitely

103. McNeil Consumer and Specialty Patient Assistance Program

Pharmaceutical Company	McNeil Consumer and Specialty Pharmaceuticals
Program Name	McNeil Consumer and Specialty Patient Assistance Program
Program Address	PO Box 1015 San Bruno CA 94066
Medicines On Program	Concerta, Flexeril, Vermox Tablet
Phone Number	866-727-4626
Guidelines and Notes	Patients must be US resident and have no third party insurance for prescriptions. If a patient has insurance for generic drugs only, they will help if patient otherwise meets their guidelines. The patient must also meet income guidelines that they do not disclose.
Initiating Enrollment	Someone from the doctor’s office must call to get the application, they wiill fax it out. The completed application can faxed or mailed back.
Health Provider’s Role	The doctor’s must fill out a section and sign. The prescription is a part of the application, be sure to note a 90 day supply.
Patient’s Role	The patient must fill out a section with detailed financial and insurance questions. The patient must also attach proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	Concerta is sent in a 6 month supply, Flexril and Vermox Tablets are sent in a 3 month supply.
Refills	To get another supply fill out another application and send it in. You can photocopy the orginial application BUT the signatures can not be photocopied as long as there are no changes. After one year all new paperwork must be sent in.
Limit	Indefinitely

104. Medimmune Assistance Program

Pharmaceutical Company	Medimmune, Inc.
Program Name	Medimmune Assistance Program
Program Address	PO Box 222197 Charlotte, NC 28222-2197
Medicines On Program	Cytogam 20ml, Cytogam 50ml, RespiGam Injection 20ml, RespiGam Injection 50ml, Synagis Injection 100 mg
Phone Number	877-480-8082
Guidelines and Notes	Patients must have no health insurance, and meet the income/asset expense parameters of the program, which are not disclosed. Patient must also be a US citizen or legal alien being treated by a US based doctor.
Initiating Enrollment	Provider needs to call and they will fax an application and information. A completed application can be faxed back but originials must be mailed in.
Health Provider’s Role	Physician completes and signs application. If a patient is approved a product request form is faxed to the physician’s office. The physician’s office must fill it out and fax it with a copy of the doctor’s DEA numberfor the patient to begin getting the medication. Be sure to keep the originial.
Patient’s Role	The patient (or parent or gaurdian) must fill out a section on income and insurance and sign the application.
How Dispensed	The medication is sent to doctor’s office
Amount Dispensed	The medication is sent in one month supplies.
Refills	After the month is up, then the physician must fax back another product request for another month’s supply. After six months a new application is needed.
Limit	Unspecified.

105. Menomune Patient Assistance Program

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Menomune Patient Assistance Program
Program Address	C/O NORD PO Box 1968 Danbury, CT 06813-1968
Medicines On Program	Medpointe Pharamaceuticals Patient Assistance Program
Phone Number	877.798.8716 ext 1
Guidelines and Notes	Patients must be US citizens or permanent residents. Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage.The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening, an application is sent to the doctor’s office.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section and sign the application
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The amount sent depends on the need of the patient and the amount awarded.
Refills	A new application is needed every year.
Limit	Indefinitely

106. Merck Patient Assistance Program

Pharmaceutical Company	Merck & Company , Inc.
Program Name	Merck Patient Assistance Program
Program Address	PO Box 690 Horsham, PA 19044-9979
Medicines On Program	Clinoril, Cosmegin Injection, Cosopt, Cozaar, Cuprimine, Depen, Demser, Dolobid, Elspar, Fosamax, Hydrocortone Tablets, Hyzaar, Indocin Oral Suspension, Lacrisert opthamlc insert, Maxalt, Mephyton Tablets, Mevacor Tablets, Midamor Tablets, Moduretic, Mustargen, Noroxin, Pepcid Oral Solution, Pepcid Tablets, Prinivil tablets, Prinzide, Propecia, Proscar Tablets, Singulair Chewable Tablets, Singulair Tablets, Stromectol Tablets, Syprine Tablets, timolol + hydrochlorothiazide, Timoptic in OCCUDOSE Preservative-Free Solution, Timoptic Opthalmic Solution, Timoptic Preservative Free Opthalmic Solution, Timoptic- XE Opthalmic Gel Forming Solution, Trusopt opthalmic Solutions, Vioxx, Zocor Tablets
Phone Number	800-727-5400
Guidelines and Notes	Program is for U.S. residents who have exhausted all possible avenues for coverage who can’t afford their medication. The patient’s income must at or be below $18,000 for an individual, at or below $24,000 for a couple or at or below 35,000 for a family of four. A provider can make a request for an exception to the income guidelines where there are extenuating circumstances. Vaccines and injectables are not available through the program. There is room on the form for prescrtipions for up to 3 Merck products. If more than three medications are needed, an additional application. See separate listing for Crixivan program.
Initiating Enrollment	A doctor or patient can call to have an application mailed out. They do not accept photocopied applications. The only applications the company will accept are originals that they have sent out.
Health Provider’s Role	The Physician/Prescriber must fill ina section with a black ball point pen. The perscription attached must not exceed a 90 day supply with a maxium of three refills. The physician must also verify that the patient meets the eligibility criteria. Stamps not accepted, the form must be hand signed.
Patient’s Role	Completes financial section on application. SIGN
How Dispensed	Will either send to patient’s home or physician/prescriber’s office, as requested.
Amount Dispensed	90 days at a time, up to 3 refills for a total of 1 year’s supply.
Refills	To get a refill the patient or doctor must call in. New application only needed once a year.
Limit	Indefinitely

107. MGI Pharma Patient Assistance Program

Pharmaceutical Company	MGI Pharma, Inc.
Program Name	MGI Pharma Patient Assistance Program
Program Address	PO BOX 6235 San Bruno, CA 94066
Medicines On Program	Aloxi, Hexalen 50 mg, Salagen 5 mg
Phone Number	888-743-5711
Guidelines and Notes	The patient must not exceed a pre-determined limited based on a percentage of the Federal Poverty Level (not disclosed.) The patient must also have no priviate insurance, no prescription coverage under Medicaid or any other state assistance program. Assets are included in their determination (excluding primary home and car.) There is a seperate application for Aloxi, but protocol is the same.
Initiating Enrollment	Anyone can call for application, but they will only send it to the doctor’s office. The blank application can be copied. The completed applcation can be mailed or faxed back.
Health Provider’s Role	Doctor completes, signs and must attach a copy of the State License. Do not attach a seperate prescription, it is built into the form.
Patient’s Role	The patient must fill out a page of the application, including quesitons about insurance and income. The patient must prepared to provide proof of income later in the process.
How Dispensed	The medication is sent to the doctor’s office within 2 business days by Fed Ex.
Amount Dispensed	Hexalen and Aloxi is sent in a 30 day supply and Salagen is sent in a 90 day supply.
Refills	To get a refill the doctor must call the company. After a year a whole new application is needed.
Limit	Indefinite

108. Millenium Patient Assistance for Velcade

Pharmaceutical Company	Millenium Pharmaceuticals, Inc.
Program Name	Millenium Patient Assistance for Velcade
Program Address	PO Box 986 San Bruno, CA 94066
Medicines On Program	Velcade
Phone Number	866-835-2233, Option #2
Guidelines and Notes	Patient must live in the US, and must have a FDA approved diagnosis, and have failed at least two prior therapies. The patient’s insurance can not cover the medication at all.
Initiating Enrollment	Anyone can call to get an application, which will be faxed out. The blank application can be copied. The completed application can be faxed or mailed back to the company.
Health Provider’s Role	The doctor must fill out a section and sign the application. A prescription will be requested later in the process.
Patient’s Role	The patient must fill out a section and sign the application. The patient must also attach proof of income.
How Dispensed	The medication is sent to the doctor’s office
Amount Dispensed	A one month supply is sent out a one time.
Refills	For refills the company calls the doctor’s office to see if another supply is needed. Once a year a new application is needed. (The company will contact the patient for this.)
Limit	Indefinite

109. Mission Pharmaceutical Patient Assistance Program

Pharmaceutical Company	Mission Pharmacal Company
Program Name	Mission Pharmaceutical Patient Assistance Program
Program Address	Customer Services PO Box 786099 San Antonio, TX 78278-6099
Medicines On Program	Thiola, Urocit-K
Phone Number	800-292-7364
Guidelines and Notes	The patient must not have any insurance. The patient must fall below the Federal Poverty Level to be eligible for the program.
Initiating Enrollment	The doctor must write a letter to the company on letter head and fax or mail it in. The letter must include patient’s medical history. Packet of information is sent back, including an application. The completed application should be mailed.
Health Provider’s Role	Fill out the application and sign a section.
Patient’s Role	The patient must provide detailed information about income and insurance. The patient must also provide proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A 3 month supply is sent at one time.
Refills	Every three months a new application is needed. Every year the proof of income is needed.
Limit	Indefinitely.

110. MS Lifelines

Pharmaceutical Company	Serono Laboratories, Inc.
Program Name	MS Lifelines
Program Address	1 Techinology Place Rockland, MA 02370
Medicines On Program	Rebif For Subcutaneous Injection
Phone Number	877-447-3243
Guidelines and Notes	Patients must have no insurance,or no prescription coverage, or have a high co-pay (over 50$). This program is based on the patient’s income levels. Some patients may have to buy the first box but then get the rest of the year free. Some patients may have to buy the medication then send the receipt in for the refund.
Initiating Enrollment	Physician must fax a prescription to the company, the company contacts the patient and sends out an application to the patient.
Health Provider’s Role	The only thing the doctor’s office must write the prescription for one year.
Patient’s Role	The patient fill out the application which has questions about financial and insurance information. The patient must also send in proof of income.
How Dispensed	The medication is sent to the patient’s house.
Amount Dispensed	A 3 month supply is sent out.
Refills	The company will contact the patient regarding refills, if getting medication is being delivered. After a year a new applicati on is needed.
Limit	Indefinite.

111. Mylan Clozapine Prescription Access System

Pharmaceutical Company	Mylan Pharmaceuticals
Program Name	Mylan Clozapine Prescription Access System
Program Address	P.O Box 4310 Morgantown, WV 26504-1310
Medicines On Program	Clozapine 100mg, Clozapine 25mg
Phone Number	888-823-7835
Guidelines and Notes	There are two programs for Clozapine, IVAX and Mylan both manufacture Clozapine and both have a program. There are two steps and two sets of paperwork for this program. The first step is to register the patient, which is required for any patient taking Clozapine regardless of insurance or finanicial situations. This is a two page form that the patient, physician and pharmacist must fill out. This is the Prescription Access System. (To register a patient for this call 1-800-843-9915 or on-line at www.mylan-closapine.com.) For the Patient Assistance Program: The patient must be a US resident and the physician feels that the patient is in need of assistance. The patient must also be below their guidelines (family of 1= $13,110, family of 2 = $16,875)
Initiating Enrollment	Both the Registration form and the Patient Assistant Program application can be copied, and faxed out to people. Completed forms and applications can also be faxed back.
Health Provider’s Role	The physican must fill out a section and sign it. The pharmacy that the medication will sent to must also fill out a section. The pharmacy must be willing to distribute the medication at no charge.
Patient’s Role	Minimal information required, would be on-file for the Registration form. The patient must provide verification of income and that insurance coverage was denied.
How Dispensed	The medication is sent to the pharmacy indicated on the application.
Amount Dispensed	A 90 day supply is sent to the pharmacy.
Refills	A refill is sent every 90 days, automatically. After a year a new application is needed.
Limit	Indefinitely

112. NABI Reimbursement Program for PhosLo

Pharmaceutical Company	NABI Biopharmaceuticals
Program Name	NABI Reimbursement Program for PhosLo
Program Address	PO Box 22157 Charlotte, NC 28222-2157
Medicines On Program	PhosLo
Phone Number	800-789-2099
Guidelines and Notes	They will help as long as this is used for an FDA approved use. The patient must be US citizen, with no medical insurance. If there is medical insurance, the company will verify benfits. The patient must fit within in house income guidelines which they don’t disclose. This is not a replacement program, so the patient should be enrolled before starting the medicaion.
Initiating Enrollment	Anyone from the doctor’s office can call to register patient by phone, then an application sent. Application is patient speciifc and must be mailed back.
Health Provider’s Role	Doctor completes and signs a section of the application. A prescription is part of application.
Patient’s Role	The patient must provide detailed financial and insurance information needed, provide proof of income, and sign the application.
How Dispensed	The medication is sent to doctor’s office.
Amount Dispensed	As much as needed, there is no guidelines for the amount.
Refills	A new application is needed every 6 months, but proof of income is only needed once a year.
Limit	Indefinite

113. Nebupent Patient Assistance Program

Pharmaceutical Company	American Pharmaceutical Partners, Inc.
Program Name	Nebupent Patient Assistance Program
Program Address	Attn: Maryanne Mares 1101 Perimeter Drive, Suite 300 Schaumburg, IL 60173
Medicines On Program	Nebupent
Phone Number	847-330-1289
Guidelines and Notes	The patient must be finanically unable to afford the medication and have no prescription insurance for the medication.
Initiating Enrollment	Provider writes letter on letterhead saying that they have determined patient to be indigent and lacking prescription coverage. Also include shipping address which will be where the product will be administered.The doctor must indicate the amount and stregthe of the medication needed and include a copy of the DEA number and state license number.
Health Provider’s Role	Not Applicable
Patient’s Role	Patient must let doctor know they cannnot pay for medicine and have no prescription coverage.
How Dispensed	Sends medicine to whomever will administer the product — provide street address. Doctor must sign and return contract saying product will not be resold or diverted to another patient.
Amount Dispensed	Usually a six month supply is sent out.
Refills	Send another letter.
Limit	Indefinitely

114. Novantrone Patient Assistance Program

Pharmaceutical Company	Serono Laboratories, Inc.
Program Name	Novantrone Patient Assistance Program
Program Address	475 Brannan Street, Suite 430 San Francisco, CA 94107
Medicines On Program	Nebupent Patient Assistance Program
Phone Number	877.447.3243, ask for this program.
Guidelines and Notes	The patient must be a US resident with no private or public healthcare. The patient must also meet certain financial guidelines which are not disclosed.
Initiating Enrollment	The doctor treating the patient must call the start the process. The patient specific application is mailed to the doctor’s office. The completed application can be faxed back.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section and sign the application. The patient also needs to provide proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A 3 month supply is sent out at one time.
Refills	If a refill is needed, the doctor’s office must request a form that needs to be filled and sent back to get a refill. Every year a new application is needed.
Limit	Indefinitely

115. Novartis Oncology Reimbursement Hotline

Pharmaceutical Company	Novartis Pharmaceuticals
Program Name	Novartis Oncology Reimbursement Hotline
Program Address	Not available.
Medicines On Program	Femara, Gleevec, Zometa
Phone Number	800-282-7630
Guidelines and Notes	This program is for patients who need assistance with medication. They do not help with insurance co-pays. Eligibility is based on income and assets. The company prefers to communicate via the phone or fax. The company also does insurance verifcations. The hotline is open from 6.00am-5.00pm PST.
Initiating Enrollment	Anyone can call for an application but they prefer that someone from the provider’s office do so. Completed applications can be faxed back.
Health Provider’s Role	The entire application can be filled out by someone in the doctor’s office or a patient advocate. After the application is faxed back, they request someone call after 4 hours to insure the fax went through.
Patient’s Role	Income and insurance information needed. Once the application is sent in the company calls the patient to get more information. Proof of income may be required.
How Dispensed	Gleevec and Femara are sent to patient. Zometa is sent to the doctor’s office.
Amount Dispensed	One month supply of Gleevec, 3 month supply of Zometa and Femara.
Refills	The company sends a fax to the doctor’s office that needs to be checked and sent back. The doctor’s office can call the pharmancy department if the supply is getting low (866-884-5906) After a year a new application is needed.
Limit	Unspecified

116. Novartis Patient Assistance Program

Pharmaceutical Company	Novartis Pharmaceuticals
Program Name	Novartis Patient Assistance Program
Program Address	PO Box 66556 St. Louis MO 63166-6556
Medicines On Program	Clozaril, Comtan, Desferal, Diovan, Diovan HCT, Elidel Cream 1%, Exelon, Famvir, Focalin, Lamisil, lescol, Lescol XL, Lotrel, Miacalcin, Neoral, Ritalin LA, Sandimmune, Neoral, Gengraf, Sandostatin , Sandostatin LAr Depot, Starlix, Tegretol, Trileptal, Zelnorm
Phone Number	800-277-2254
Guidelines and Notes	Patients must be US residents with no prescription coverage (public or private). The patient must also meet income guidelines that are not disclosed.
Initiating Enrollment	Provider or Patient calls for application, or it can be downloaded from www.pharma.us.novartis.com/novartis/pap/pap.jsp. Once completed, the form, financial documentation and prescription must be mailed in. Physician will receive written notification of patient’s eligibility for program.
Health Provider’s Role	Provider completes lower portion of application with signature and date and DEA#, and attaches a prescription for a 3 month supply (written to equal stock bottle quantities).
Patient’s Role	The patient must fill out a section, sign and attach proof of income (list on the application.)
How Dispensed	The medications are sent to physician’s office.
Amount Dispensed	Most medications are sent in a 90 day supply. A few use a pharmacy card.
Refills	A Refill Mailer is included with medication. The patient gets a new prescription and mails it about a month before supply runs out. Or someone in the office can the company and get a reorder. Every year a new application is needed, with documentation. A letter will be sent out to remind the patient to reapply.
Limit	Indefinite

117. Novo Nordisk Patient Assistance Program

Pharmaceutical Company	Novo Nordisk Pharmaceuticals, Inc.
Program Name	Novo Nordisk Patient Assistance Program
Program Address	PO Box 1096 Somerville, NJ 08876
Medicines On Program	NovoFine 30, NovoFine 31, Novolin 70/30 InnoLet, Novolin 70/30 PenFill, Novolin 70/30 vials, Novolin N InnoLet, Novolin N PenFill, Novolin N Vials, Novolin R InnoLet, Novolin R PenFill, Novolin R Vials, NovoLog 10 ml Vials, NovoLog FlexPen, NovoLog Mix 70/30 10 mL Vials, NovoLog Mix 70/30 FlexPen, NovoLog Mix 70/30 PenFill 3mL Cartridges, NovoLog PenFill 3 ml Cartridges , NovoPen 3, Prandin 0.5 mg, Prandin 1 mg, Prandin 2 mg
Phone Number	800-727-6500
Guidelines and Notes	California residents need to use a different form. The patient can not have or qualify for any government or private prescription coverage. The patient’s total annual household income must be at or below the 200% of the Federal Poverty Guidelines.
Initiating Enrollment	Anyone can call for an application and it will be automatically faxed out. The application can be copied. The completed application must be mailed back.
Health Provider’s Role	Doctor must fill out a section including a signature, DEA#, phone number and address. The doctor must also attach a perscription.
Patient’s Role	The patient must fill out a section, sign the application and attach proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	3 month supply is sent out one month at a time.
Refills	After three months a new application is needed.
Limit	A maxuim of a one year total supply may be granted.

118. Novo Nordisk Women Health Care

Pharmaceutical Company	Novo Nordisk Pharmaceuticals, Inc.
Program Name	Novo Nordisk Women Health Care
Program Address	P.O. Box 1096 Somerville, NJ 08876
Medicines On Program	Activella, Vagifem
Phone Number	866-668-6336 ext #1
Guidelines and Notes	Applicants must be at or below 200% of the Federal Poverty Level and can not qualify for any public or private prescription coverage. Allow up to 10 buisness day for processing and delivery of medication.
Initiating Enrollment	Call the above number to get an application automatically faxed out. The completed application should be mailed back.
Health Provider’s Role	The doctor must fill out a section of the application, sign and attach a prescription.
Patient’s Role	The patient must fill out a section of the application, sign and attach proof of income.
How Dispensed	The medicaiton is send to the doctor’s office.
Amount Dispensed	The medication is sent in a 5 month supply. For Activella the prescription must be made out for a 5 pack of 1×28 tablets.
Refills	After 5 months a new application is needed.
Limit	Indefinitely

119. Odyssey Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	Odyssey Pharmaceuticals, Inc.
Program Name	Odyssey Pharmaceuticals Patient Assistance Program
Program Address	72 Eagle Rock Ave East Hanover, NJ 07963
Medicines On Program	Antabuse, Nystatin Vaginal Tablet, Surmontil 100 mg, Surmontil 25 mg, Surmontil 50 mg, Urecholine 10mg, Urecholine 25mg, Urecholine 5 mg, Urecholine 50 mg, Vivactil 10 mg, Vivactil 5 mg, Vospire ER
Phone Number	1-877-427-9068
Guidelines and Notes	They have an informal program. See below.
Initiating Enrollment	The physician’s office must send a letter on letterhead stationary stating the patient’s name and information, the product requested and why the patient can not afford the medication. The physician must also write a prescription and attach it to the letter. The completed letter must be mailed back.
Health Provider’s Role	See Above
Patient’s Role	The patient just needs to tell the phyisician they are in need.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The medication is sent in a stock 100 tablet bottle.
Refills	After three months another letter can be sent out.
Limit	Indefinitely.

120. Open Gate Med Assist Program

Pharmaceutical Company	Gate Pharmaceuticals
Program Name	Open Gate Med Assist Program
Program Address	1090 Horsham Rd. PO Box 1090 North Wales PA 19454
Medicines On Program	Galzin Capsules 25 mg, Galzin Capsules 50 mg, Orap Tablets 1 mg, Orap Tablets 2 mg
Phone Number	800-292-4283 ext 8921
Guidelines and Notes	Patient must be a US resident who does not qualify for government or private prescription programs. Income requirements are as follows: $18,000 or less for individuals, $24,000.00 of less for couples, $35,000. or less for a family of four.
Initiating Enrollment	The physician’s office must call to get start the application process. The application is patient specific, and cannot be copied. The company will fax the applicaton to the doctor. The completed application must be mailed back.
Health Provider’s Role	Physician must fill out and sign their section. A prescription must be up to a 90-day supply with three refills.
Patient’s Role	The patient must also fill out a patient section and sign it. The application ask for financial and insurance information and also requires proof of income
How Dispensed	The medication is sent to the doctors office in stock bottle of 100 for Orap and 250 for Galzin. Allow 15 days for processing.
Amount Dispensed	A three month supply is sent at one time.
Refills	The prescription may be written for up to one year as long as there is no more than 3 refills on a single prescription. The physician must phone refill requests in. Once a year a whole new application is needed.
Limit	Indefinite

121. Orfadin Patient Assistance Program

Orfadin
Pharmaceutical Company
Program Address	Orfadin Patient Assistance Program C/O NORD PO Box 1968 Danbury, CT 06813-1968
Toll Free Phone Number	888.454.8860
Guidelines and Notes	Patients must be US citizens or permanent residents. Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage.The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening, an application is sent to the doctor, patient or social worker.
Health Provider’s Role	The doctor must fill out a section and sign the application. The doctor must also attach a prescription
Patient’s Role	The patient must fill out a section, sign the application and attach proof of income.
How Dispensed	The medication is sent to the doctor’s office or the patient’s home.
Amount Dispensed	The amount sent depends on the need of the patient and the amount awarded.
Refills	A new application is needed every year.
Limit	Indefinitely

122. Ortho-McNeil Patient Assistance Program

Pharmaceutical Company	Ortho-McNeil Pharmaceutical
Program Name	Ortho-McNeil Patient Assistance Program
Program Address	PO Box 969 San Bruno CA 94066
Medicines On Program	Bicitra, Ditropan Tablets, Ditropan XL, Elmiron Capsules, Floxin tablets, Grifulvin V Suspension, Grifulvin V Tablets, Haldol Decanoate Injection, Haldol Injection, Levaquin 250 mg, Levaquin 500 mg, Levaquin 750 mg, Mycelex Troche, Neutra-Phos, Neutra-Phos-K, Pancrease Capsules, Pancrease MT Capsules, Regranex Gel 0.01%, Retin-A Cream, Retin-A Gel, Spectazole Cream, Terazol 3 Suppositories, Terazol Cream, Tolectin, Topamax Tablets, Ultracet, Ultram Tablets, Urispas Tablets
Phone Number	800-577-3788
Guidelines and Notes	Patients must be US resident and have no third party insurance for prescriptions. If a patient has insurance for generic drugs only, they will help if patient otherwise meets their guidelines. The patient has to meet insurance guidelines that are not disclosed.
Initiating Enrollment	Prescriber calls for application and it will be faxed out. The completed application can be faxed or mailed back to the company.
Health Provider’s Role	The doctor must fill out a section, sign it and attach a prescription.
Patient’s Role	The patient must fill out a section with detailed financial and insurance questions. The patient must also attach proof of income.
How Dispensed	Medication is sent to the prescriber’s office.
Amount Dispensed	A 90 day supply is sent, except for Ultram and Ultracet which is sent in a 30 day supply.
Refills	They suggest making a copies vof the unsigned application because you have to reapply every three months in order to get refills, but no new documentation is needed. After one year the financial paperwork is needed again.
Limit	Indefinitely

123. Ovation Pharmaceuticals Patient Assitance Program

Pharmaceutical Company	Ovation Pharmaceuticals
Program Name	Ovation Pharmaceuticals Patient Assitance Program
Program Address	4 Parkway North Deerfield IL, 60015
Medicines On Program	Chemet, Panhematin, Peganone
Phone Number	800.455.1141
Guidelines and Notes	They don’t have a formal program, but if is a patient is need contact the company, and they will review each case.
Initiating Enrollment	Patient or doctor can call the start the process. Information is collected and passed on.
Health Provider’s Role	Once the information is collected the company will contact the doctor. The company will fax a form to the doctor’s office to receive the medication if the patient is accepted.
Patient’s Role	Patient needs to tell the doctor that s/he is in need.
How Dispensed	The medication is sent out to the doctor’s office.
Amount Dispensed	The amount sent out varies according to the medication and the need.
Refills	Usually the patient will contact the company to get a refill.
Limit	Indefinitely

124. Oxandrin Reimbursement and Patient Assistance Program

Pharmaceutical Company	BTG Pharmaceuticals
Program Name	Oxandrin Reimbursement and Patient Assistance Program
Program Address	PO Box 222114 Charlotte, NC 28222-2114
Medicines On Program	Oxandrin
Phone Number	866-692-6374 #2
Guidelines and Notes	Patient must have no third party assistance and must first apply for all public assistance in his or her state and be denied. The patient must also be a legal resident of the US. The patient must also meet financial guidelines that are based on the Federal Poverty Guidelines.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. The blank application can be copied. The completed application can be mailed or faxed back to the company. If faxed, the orginial application and prescritip must be sent in as well.
Health Provider’s Role	Doctor completes a section and signs the application. The doctor must also attach prescription for a 30 day supply and up to two refills.
Patient’s Role	The patient must fill out a section that asks for detailed insurance and financial information. The patient also needs to sign the application.
How Dispensed	The medication will be sent to the patient’s home or doctor’s office.
Amount Dispensed	The medication will be sent out in a one month supply.
Refills	The refills are sent out automatically. Once the refills are filled the company will fax the doctor a form that will need to be filled out for the next three months. In addition, the company sends letter to the patient every quarter and to the doctor every other month, that need to be filled out to keep the medication coming the following shipment. Every six months a whole new application is needed.
Limit	Indefinitely

125. Pegassist Patient Assistance Program

Pharmaceutical Company
Program Name	Pegassist Patient Assistance Program
Program Address	5870 Trinity Parkway, Suite 600 Centerville, VA 20120
Medicines On Program	Copegus Tablets, Pegasys
Phone Number	800-387-1258
Guidelines and Notes	The patient must be unisured for this medication. The patient also must meet financial guidelines that are not disclosed.
Initiating Enrollment	The patient or doctor can call for the pre-screening. After the pre-screeening is completed, a patient specific application is sent to the doctor’s office to completed. The completed application can be faxed back.
Health Provider’s Role	The doctor needs to fill out a section, sign the application and attach a prescription.
Patient’s Role	The patient must sign the application and attach proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A one month supply is sent out.
Refills	The company will fax a Refill Request to the doctor who must fill it out and return it.
Limit	Indefinitely

126. Pfizer Connection to Care

Pharmaceutical Company	Pfizer, Inc.
Program Name	Pfizer Connection to Care
Program Address	PO BOx 66585 St. Louis MO 63166-6585
Medicines On Program	Accupril, Accuretic, Antivert, Arthrotec, Bextra, Cardura, Celebrex, Covera HS, Cytotec, Detrol, Detrol LA, Diabinese, Dilantin, Dostinex, Feldene, Glucotrol, Glucotrol XL, Glyset, Lipitor, Lopid 600 mg, Minipress, Minizide, Navane, Neurontin, Norvasc, Procardia, Procardia XL, Relpax, Sinequan, Zonalon, Viagra, Vibramycin, Vistaril, Xalatan, Zarontin, Zoloft, Zyrtec-D
Phone Number	800-707-8990
Guidelines and Notes	The patient’s income must be at below $16,000 for a single household income or less than $25,000 for family income. The patient cannot have or be eligble for any public or private insurance that covers medications.
Initiating Enrollment	Anyone can call for an application through an automated fax program The completed application must be mailed back.
Health Provider’s Role	The healthcare provider must fill out a section including DEA number, and signature (no stamps accepted.) The healthcare provider must also write out a prescription that will be mailed in.
Patient’s Role	The patient needs to complete patient section, sign and attach proof of income. Last year’s tax returns and supporting docuements are also required.
How Dispensed	The medication is sent to the provider’s office, be sure to write a street address not a P.O. Box.
Amount Dispensed	Three month supply, usually sent 3 to 4 weeks after receipt of the request.. Physician is sent a letter eligibility status of patient. Every three months a new application must be filled out.
Refills	Every three months a new application with a new prescription must be mailed out. After a year a new application including proof of income must be sent in.
Limit	Indefinite

127. Pfizer Patient Assitance Program for Diflucan, VFEND, Zithromax

Pharmaceutical Company	Pfizer, Inc.
Program Name	Pfizer Patient Assitance Program for Diflucan, VFEND, Zithromax
Program Address	PO Box 230518 Centreville, VA 20120-9903
Medicines On Program	Diflucan, VFEND, Zithromax
Phone Number	800-869-9979
Guidelines and Notes	Call 8:30am-5:30pm M-F. Single patients must have income less than $25,000; patient with dependents less than $40,000 a year. Patient can’t have any form of prescription insurance. Pfizer doesn’t reimburse pharmacies for products already dispensed. Patients must be residents of the US. The Zithromax program is intended for patients taking 1200 mg weekly for the prevention of MAC. Medicines must be used for outpatient use. If the patient is in-patient or needing more for acute uses, a letter must attached explaining why.
Initiating Enrollment	They prefer that the doctor, a patient advocate or social worker to call to start the process. Patient and doctor information is taken over the phone, then a patient specific application is sent to the doctor’s office.
Health Provider’s Role	Doctor completes, signs, and attaches prescription. Doctor also indicates the length of anticipated therapy.
Patient’s Role	The patient must provide basic information and sign the application.
How Dispensed	The medication is sent to the doctor’s office. The wait time once the application is returned is 4-6 days.
Amount Dispensed	Medication is usually sent out in 90 day supply unless an acute case then a letter is needed explaining why.
Refills	For a refill, a whole new application and prescription is needed. Call 21 days before the current supply runs out.
Limit	Indefinitely.

128. Pharmion Corporation Patient Assistance Program

Pharmaceutical Company
Program Name	Pharmion Corporation Patient Assistance Program
Program Address	2525 28th St, Suite 200 Boulder, CO 80301
Medicines On Program	Innohep
Phone Number	1-866-742-7646, Option 4
Guidelines and Notes	The patient must not qualify for government assistance or have third party coverage and are financially unable to pay for the product. The patient must also be a US resident. This company has two applications, one for patient assistance and one for product replacement.
Initiating Enrollment	Anyone call for an application and it can be faxed out. The completed application should be faxed back.
Health Provider’s Role	The physician must fill out a section including the prescription information and state license number. The phyisican must also sign the application.
Patient’s Role	The patient must fill out section that asks for Gross Monthly Household Income and alternate sources of funding. The patient must also be able to provide proof of income (bank statement and W-2) if requested. The patient must also sign the application.
How Dispensed	The medication is sent to the doctor’s office. If the application is recieved before 2pm EST then the medication will be delivered the next buisness day. If the application is received after 2pm EST then the medication will be delivered within 2 buisness days (Add one extra day for Fridays and holidays.)
Amount Dispensed	The amount sent out depends on the patient’s diagnosis. The maxium sent out is a 30 day supply.
Refills	The company will contact the patient and the physician for refills, if a refill is needed the company will ask for required information. After a year a whole new application is needed, with documentation.
Limit	Indefinitely

129. Pletal Patient Assistance Program

Pharmaceutical Company	Otsuka America Pharamaceutical, Inc
Program Name	Pletal Patient Assistance Program
Program Address	PO Box 2139 Lakewood, NJ 08701-2139
Medicines On Program	Pletal
Phone Number	800-992-4546
Guidelines and Notes	The patient must not have any private or public perscription coverage and met financial guidelines that are not disclosed.
Initiating Enrollment	The doctor or the patient can call to get the application mailed to either the doctor’s office or the patient’s home. The completed application must be mailed.
Health Provider’s Role	The doctor must fill out a section of the application and sign.
Patient’s Role	The patient must fill out a section of the application, sign it and provide proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A four month supply is sent out.
Refills	A month before the current prescription is to run out the company sends the patient a new application is sent out that must be filled out and returned.
Limit	Indefinitely

130. Prevacid Program

Pharmaceutical Company	TAP Pharmaceuticals, Inc.
Program Name	Prevacid Program
Program Address	PO Box 66586 St. Louis MO 63166-6586
Medicines On Program	Prevacid 15 mg, Prevacid 30 mg
Phone Number	800-830-1015, option 1
Guidelines and Notes	Call between the hours of 7:30am-5pm CST. Patient must at or below the Federal Poverty Level. The patient can have insurance coverage but not for Prevacid.
Initiating Enrollment	Someone from the doctor’s office can call for an application and it will automatically be faxed out. The application can be copied. The completed application must be faxed back from the doctor’s office.
Health Provider’s Role	Doctor fills in all information including DEA number, dosage and signature.
Patient’s Role	Provide basic information including income and financial and sign the application.
How Dispensed	The medication is shipped directly to the doctor’s office within 7-10 working days. Application needs to give a street address.
Amount Dispensed	A 60-day supply is sent out each shipment.
Refills	Prescriber can call in for refills. Allow up to five business days for processing. After a year a whole new application is needed.
Limit	Indefinite.

131. PROCTRITline

Pharmaceutical Company	Ortho Biotech Products, L.P.
Program Name	PROCTRITline
Program Address	PO Box 1016 San Bruno, CA 94066
Medicines On Program	Doxil, Leustatin, Procrit
Phone Number	800-553-3851
Guidelines and Notes	The company also provides insurance verification. But the program is for patients that have no insurance, reached the insurance limits or their insurance doesn’t cover the medication and are under the financial guidelines that they don’t release.
Initiating Enrollment	Anyone can call to get an application faxed out. The blank application can be copied. The completed application can be faxed back but also needs to be mailed in if the patient is accepted.
Health Provider’s Role	The doctor needs to complete a section and sign.
Patient’s Role	The patient must provide proof of income and sign the application.
How Dispensed	The medication can be sent to the doctor’s office or the patient can recieve a pharmacy card that they bring to the pharmacist each month.
Amount Dispensed	One application is good for six month supply but is sent out one month at a time.
Refills	The company will call the doctor’s office for refill information. After six months the company contacts the patient to renew. Same form is used but the proof of income is only needed once a year.
Limit	Indefinitely

132. Procter & Gamble Patient Assitance Program

Pharmaceutical Company	Proctor and Gamble Pharmaceuticals, Inc
Program Name	Procter & Gamble Patient Assitance Program
Program Address	c/o Express Scripts PO Box 66553 St. Louis MO 63166-66553
Medicines On Program	Actonel, Asacol, Dantrium, Didronel, Macrobid, Macrodantin
Phone Number	800-830-9049
Guidelines and Notes	To qualify, a patient must have exhausted all sources of prescription coverage through private or public insurance. Each patient’s case is handled on an indivdual basis. Eligibility is based on income and medical expenses.
Initiating Enrollment	Anyone can call them for an application and they will fax the application to the dcotor’s or mail it to the patient. It can be copied. The completed application can be faxed (from doctor’s office) or mailed back.
Health Provider’s Role	Practitioner completes, signs and attaches an original perscription.
Patient’s Role	The patient must fill out a section of the application and attach proof of income.
How Dispensed	Medication is sent to the patient’s house and requires a signature upon delivery.
Amount Dispensed	The medication supplied depends on diagnosis and need, but generally a three month supply is provided for chronic medication.
Refills	A new prescription is needed for each new supply, after one year a whole new application.
Limit	Indefinitely

133. Prograf and Protopic Patient Assistance Program

Pharmaceutical Company	Fujisawa Healthcare, Inc. Prograf Hotline
Program Name	Prograf and Protopic Patient Assistance Program
Program Address	PO Box 221644 Chantilly, VA 20153-1644
Medicines On Program	Prograf 0. 5 mg, Prograf 1 mg, Prograf 5 mg, Protopic 0.03% Ointment, Protopic 0.1% Ointment
Phone Number	800-477-6472
Guidelines and Notes	The patient must be a permanent US resident and meet financial and insurance guidelines that are not disclosed. If a patient has been on Prograf for a while, there is an option enroll in a long term program which provides medication for a full year without reapplication.
Initiating Enrollment	Health care provider calls to register patient by phone, with insurance, income and medical information about the patient. Then the application is faxed to the provider’s office. The completed application can be faxed back, but it also needs to be mailed back.
Health Provider’s Role	The provider must complete a section and sign the application.
Patient’s Role	The patient must also fill out a section, sign and attach proof of income and insurance termination letter if applicable.
How Dispensed	The medications are distributed through a company that require a $20 shipping charge. The meds are sent to the patient’s house unless requested to be sent to the doctor’s office. The medication can be sent to either the patient’s home or the doctor’s office.
Amount Dispensed	Prograf is sent in two 3-month supplies. Protopic is sent in two 6-month supplies.
Refills	To reapply the health care provider needs to call to restart the process. The company will send out reminder letters.
Limit	Unspecified

134. Proleukin Reimbursement Hotline

Pharmaceutical Company
Program Name	Proleukin Reimbursement Hotline
Program Address	PO Box 221644 Chantilly, VI 20153
Medicines On Program	Proleukin
Phone Number	866-385-4729
Guidelines and Notes	Patient must be a US resident, and meet income requirements that are not disclosed. The patient must also be uninsured for the medications.
Initiating Enrollment	The doctor’s office must call to start the process before the start of therapy. If the patient passes the prescreening done over the phone, a patient specific application is sent to the doctor’s office.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section of the application and attach proof of income.
How Dispensed	The medications to the doctor’s office.
Amount Dispensed	The amount sent is amount prescribed.
Refills	To start another round of therapy the whole process must be repeated.
Limit	Indefinitely.

135. Provigil Reimbursement Assistance Hotline

Pharmaceutical Company	National Organization for Rare Disorders (NORD)
Program Name	Provigil Reimbursement Assistance Hotline
Program Address	C/O NORD PO Box 1968 Danbury, CT 06813-1968
Medicines On Program	Provigil
Phone Number	800-675-8415
Guidelines and Notes	Anyone can call between 9am and 5pm Eastern Time. Assistance can only be provided for patients using Provigil. Though there are a number of off-label uses, at this time, the only FDA approved use is for narcolepsy. Patients can’t have any type of prescription coverage.
Initiating Enrollment	Anyone can call to start the application process. The application is sent to the patient’s home. The completed application should be mailed back.
Health Provider’s Role	The physician must fill out a section of the application and sign it.
Patient’s Role	The patient must provide financial and insurance information and sign the form. The patient must also attach proof of income.
How Dispensed	Vouchers are sent to the patient that can be redeemed at a pharmacy.
Amount Dispensed	Unclear
Refills	Once a year a new application is needed.
Limit	Not specified.

136. Purdue Frederick Patient Assitance Program

Pharmaceutical Company	Purdue Pharma
Program Name	Oxy IR, Oxycontin, OxyFast
Program Address	Not available, but it is on the application
Medicines On Program	Oxy IR, Oxycontin, OxyFast
Phone Number	800-599-6070
Guidelines and Notes	For patients who have no coverage and aren’t entitled to Medicaid. The patient must fall under financial guidelines that are not disclosed. MS Contin and MSIR are no longer on the program for new applicants. Patients already enrolled in the program will be able to finish out their course of treatment.
Initiating Enrollment	Doctor’s office must start the process by calling and asking for an application with the patient’s name on it. The application will then be faxed. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor needs to complete a section, sign and attach a prescription.
Patient’s Role	The patient needs to fill out a section, sign the application and attach proof of income.
How Dispensed	The medicine is sent to patient by FedEx overnight.
Amount Dispensed	The medication is sent in a 30 day supply.
Refills	Patient needs to send a new prescription every month to get refills. After a year a whole new application is needed.
Limit	Indefinitely

137. Purinethol Access Program

Pharmaceutical Company	Gate Pharmaceuticals
Program Name	Purinethol Access Program
Program Address	Not Applicable
Medicines On Program	Purinethol 50 mg Tablets
Phone Number	877.254.1039
Guidelines and Notes	Patients must be a US resident, not be eligible for any prescription benifits through any private or public program. The patient must also meet financial guidelines that are not disclosed.
Initiating Enrollment	Anyone can call to get an application faxed out. The application can also be downloaded at www.gatepharma.com The blank application can be copied. The completed application can be faxed back to the company.
Health Provider’s Role	The physician must fill out a section and sign the application. The prescription is built into the applicatin.
Patient’s Role	The patient must fill out a section about insurance, income and financial information. The patient must also sign the application. Please attach proof of income.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The patient is authorized for a 180 day supply sent out in 90 day.
Refills	The doctor or the patient can call for a refill. After 6 months the doctor is send a mid year attestation form, once that is filled out and returns another 180 day supply is sent out in 90 day shipments. After one year a whole new application is needed, the doctor will be sent the paperwork for that.
Limit	Indefinitely

138. RapAssist Patient Assistance Program for Rapamune

Rapamune
Pharmaceutical Company	RapAssist Patient Assistance Program for Rapamune
Program Address	RapAssist Patient Assistance Program for Rapamune 9801 Washingtonion Blvd., 9th Floor Gaithersburg MD 20878
Toll Free Phone Number	877-472-7268
Guidelines and Notes	The company can not give out any specifics of what makes a patient eligible. When the doctor calls for the presceening questions regarding the patient insurance and financial state are asked.
Initiating Enrollment	Provider must call first for a prescreening, and if appropriate an application can be mailed to the patient or the doctor’s office.
Health Provider’s Role	There is a seperate form the doctor has to fill out and return.
Patient’s Role	The patient must fill out the application and sign it.
How Dispensed	Medication is mailed to patient.
Amount Dispensed	The medication is sent out in a two month supply.
Refills	Every 2 months the medications are automatically sent out. After a new year a new application is needed.
Limit	Not specified.

139. Reliant Pharmaceuticals Rx Support Program

Pharmaceutical Company	Reliant Pharamceuticals
Program Name	Reliant Pharmaceuticals Rx Support Program
Program Address	PO Box 6842 Somerset, NJ 08875
Medicines On Program	Dynacirc CR 10 mg, Dynacirc CR 5 mg
Phone Number	866-792-2737
Guidelines and Notes	This is a program of last resort, if there are no other payment options. The patient must meet financial guidelines that are not disclosed. All applications are screened and if it appears a patient may qualify for an available state or local program, the application will be returned with a request that it be resubmitted with a denial letter from that program.
Initiating Enrollment	Doctor, patient or patient advocate may call for an application, it will be sent to the doctor’s office and is patient specific. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section, sign and attach a perscription.
Patient’s Role	The patient must fill out a section of the application, sign and attach proof of gross monthly income. The application has a list of acceptable documentation.
How Dispensed	The medicine is sent to doctor’s office via Airborne Express. Allow about 3 weeks for an initial determination.
Amount Dispensed	3 month supply is sent with refill application which doctor and patient must sign.
Refills	4th shipment comes with new application form which must be completed before patient will be approved for another year. Initial application is approved for one year.
Limit	Indefinitely.

140. Remicade Patient Assistance

Pharmaceutical Company	Centocor
Program Name	Remicade Patient Assistance
Program Address	PO Box 221709 Charlotte, NC 28222-1709
Medicines On Program	Remicade
Phone Number	866-489-5957
Guidelines and Notes	This drug is used for Crohn’s Disease and rheumatoid arthritis. The program doesn’t disclose their financial guidelines, but a patient must be a US Resident and have no insurance coverage for the medication. If you have questions, you can reach a program counselor Monday through Friday, 8:30 am to 8 pm eastern time.
Initiating Enrollment	Anyone can call for the application which can be copied. They prefer that someone from a doctor’s office calls so that the cover letter can be patient specific, but the application is not. Completed application can be faxed or mailed back.
Health Provider’s Role	Doctor completes and signs, indicating whether it is a new application or a re-application. Complete Attachment B if patient is to be infused in by an alternate provider. Once approved, the doctor fills out a form that is sent with the acceptance letter for the medication.
Patient’s Role	Detailed financial and insurance information needed. Patient is required to sign and sent in proof of income (list on application.)
How Dispensed	Drug is shipped to physician or infusion site.
Amount Dispensed	Depends on the diagnosis and amount requested on prescription.
Refills	Each time the patient needs to be infused, the doctor sends another Product Request Form. After 6 months an entirely new application is needed with proof of income.
Limit	Indefinitely.

141. Renagel Patient Assistance Program

Pharmaceutical Company	American Kindey Fund
Program Name	Renagel Patient Assistance Program
Program Address	6110 Executive Blvd., Suite 1010 Rockville MD 20852
Medicines On Program	Renagel
Phone Number	800-638-8299 x6674
Guidelines and Notes	The program is currently full and won’t be accepting applications until Sept 2004. This program is sponsored by Genzyme and administered by the American Kidney Foundation. It is for individuals who have no form of insurance and aren’t eligible for any insurance that would cover Renagel 800 mg tablets.
Initiating Enrollment	Patient’s nephrologist and social worker must call for an application.
Health Provider’s Role	Not specified.
Patient’s Role	Not specified.
How Dispensed	Not specified.
Amount Dispensed	Patients on this program receive a 6-month supply of medication.
Refills	Not Applicable
Limit	Unspecified

142. Retavase Solutions Program

Pharmaceutical Company	Centocor
Program Name	Retavase Solutions Program
Program Address	PO Box 220807 Charlotte NC, 28222-0807
Medicines On Program	Retavase
Phone Number	866- 738-2827
Guidelines and Notes	Retavase is for acute MI and is an injectable. They have two components: one is a waste and breakage program. The product has to be mixed prior to use, and once constituted it can’t be reused. In instances where the drug was mixed and then not used or broken, they would provide replacement product. The second component is a patient assistance program for once the medication is used. The patient must be a US citizen and met financial guidelines that are not disclosed. The patient must also have no coverage for the medication. The application must be sent in within one year of date of service.
Initiating Enrollment	Anyone can call for application, and it will be faxed out. A blank application can be photocopied. The completed application can be faxed or mailed back to the company.
Health Provider’s Role	Heatlh provider fills out a section of the application and sign it. There must be documention the medication used was Retavase (computer print out, bill, itemized listing, any hospital record.)
Patient’s Role	Patient needs to provide hospital with name, address and social secruity number, Gross Family Income, and insurance information.
How Dispensed	Provides replacement product hospital or doctor.
Amount Dispensed	As needed.
Refills	n/a
Limit	Up to one year after the medication has been administered.

143. Rilutek Patient Assistance Program

Rilutek, Serostim
Pharmaceutical Company	Rilutek Patient Assistance Program
Program Address	Rilutek Patient Assistance Program C/O NORD PO Box 1968 Danbury, CT 06813-1968
Toll Free Phone Number	800.459.7599
Guidelines and Notes	Patients must be US citizens or permanent residents. Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage.The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening, an application is sent.
Health Provider’s Role	The doctor must fill out a section and sign the application. The doctor must also attach a prescription
Patient’s Role	The patient must fill out a section, sign the application and attach proof of income.
How Dispensed	The medication is sent to the patient’s home.
Amount Dispensed	The amount sent depends on the need of the patient and the amount awarded.
Refills	A new application is needed every year.
Limit	Indefinitely

144. Risperdal Patient Assistance Program

Pharmaceutical Company	Janssen Pharmaceutica
Program Name	Risperdal Patient Assistance Program
Program Address	PO Box 222098 Charlotte, NC 28222
Medicines On Program	Risperdal Injectable Long Acting 25mg, Risperdal Injectable Long Acting 37.5 mg, Risperdal Injectable Long Acting 50mg, Risperdal M Tablets 0.05mg, Risperdal Oral Solution, Risperdal Tablets 0.25mg, Risperdal Tablets 0.5mg, Risperdal Tablets 1mg, Risperdal Tablets 2mg, Risperdal Tablets 3mg, Risperdal Tablets 4mg
Phone Number	800-652-6227, opt 1
Guidelines and Notes	For an individual to be eligible for the program, his or her income must be under $18,620; for a couple, the limit is $24,980. They no longer consider out of pocket medical expenses in determining eligibility.
Initiating Enrollment	Patient, guardian, physician or social worker can call for application. They will fax or mail it. The blank application can be copied. The completed application can be faxed back.
Health Provider’s Role	The provider completes a section, signs the application. A prescription is built into the application.
Patient’s Role	Income and insurance information needed as well as a signature. The patient must also attach a copy of her/his tax return if possible.
How Dispensed	The medication is sent to the doctors’s office.
Amount Dispensed	The medication is sent out in a 60 tablet bottle.
Refills	The refills are automatically sent out. The patient is enrolled initially for four months. The company sends out the application a month before it is needed for the next eight months.
Limit	Indefinitely

145. Roche HIV Therapy Assistance Programs

Cytovene, Fortovase, HIVID, Inverase, Valcyte tablets
Pharmaceutical Company	Roche HIV Therapy Assistance Programs
Program Address	Roche Medical Needs Program c/o Intele Center PO Box 4280 Gaithersburg, MD 20885
Toll Free Phone Number	800-282-7780
Guidelines and Notes	Patient can’t have any current prescription benefits. The company also has other critera, including income guidelines that they do not disclose. They will determine if there are any public assistance programs available to the patient and assist with linkage.
Initiating Enrollment	Doctor calls to register patient by phone, they will take information over the phone, and if it appears that patient qualifies for program, they will fax an application. The completed application can be faxed back.
Health Provider’s Role	Doctor completes and signs a section of the application. Prescription information is included on the application so they can expedite first shipment, but then physician must send in original prescription.
Patient’s Role	The patient needs to fill out a section with detailed financial and insurance information needed. The patient must also sign the application and attach proof of household income and insurance documentation.
How Dispensed	The medicatoin will arrive in two business days to the doctor’s office.
Amount Dispensed	The medications are sent out in a one month supply.
Refills	At end of each month the doctor’s office calls in a new prescription. Every 90 day an Update Form is sent and doctor and patient must sign and return it. After a whole new application is needed with new documentation.
Limit	Indefinitely

146. Roche Labs Patient Assistance Program

Pharmaceutical Company	Roche Pharmaceuticals
Program Name	Roche Labs Patient Assistance Program
Program Address	Medical Needs Department Roche Laboratories 340 Kingsland St. Nutley, NJ 07110-1199
Medicines On Program	Accutane 10 mg, Accutane 20 mg, Accutane 40 mg, Anaprox, Bumex Tablet 1 mg , Bumex Tablets 0.5 mg , Bumex Tablets 2 mg , Cardene Capsules 20mg, Cardene Capsules 30 mg, Demadex IV Injection 20mg/2ml, Demadex IV Injection 50mg/5ml, Demadex Tablets 10 mg, Demadex Tablets 100 mg, Demadex Tablets 5 mg, EC Naprosyn Tablets DR 375 mg, Gantanol, Klonopin Tablet 2 mg, Klonopin Tablet 0.5mg, Klonopin Wafers, Naprosyn Tablets , Rocaltrol Capsules 0.25mcg, Rocaltrol Capsules 0.5mcg, Rocaltrol Oral Solution 1 mcg/ml, Rocephin For Injection 1 gm , Rocephin For Injection 2 gm , Rocephin Powder For Injection 1 gm , Rocephin Powder For Injection 250mg, Rocephin Powder For Injection 2gm , Rocephin Powder For Injection 500mg, Valium Injection 10 mg, Valium Tablets 10 mg , Valium Tablets 2 mg, Valium Tablets 5 mg , Xenical
Phone Number	800-285-4484
Guidelines and Notes	The patient must be a US citizen or a legally in country. The patient must have no prescription coverage for the medication and can only be an out-patient. The company looks at each patient on an individual basis. For the medication Rocephin, the company will push the application through to get the medication to the doctor’s office quickly. All fields must be completed or the application will sent back.
Initiating Enrollment	Anyone can call for an application it will be sent to the doctors office. The completed application must be mailed back.
Health Provider’s Role	Doctor needs to complete a section, sign, and include her/his DEA number. The prescription is incorporated into the application.
Patient’s Role	The patient needs to provide information about household size and income and sign the application.
How Dispensed	The company sends the medicine to physician’s registered DEA address.
Amount Dispensed	The medication is sent in an up to three month supply.
Refills	3 weeks before the currently supply is up an new application is needed.
Limit	Indefinitely

147. Roche Oncoline Patient Assistance Program

Pharmaceutical Company	Roche Pharmaceuticals
Program Name	Roche Oncoline Patient Assistance Program
Program Address	5870 Trinity Parkway, Ste 600 Centreville VA, 20120-1970
Medicines On Program	Kytril, Roferon-A, Vesanoid, Xeloda
Application	Contact program for application
Guidelines and Notes	The program is intended for people with no insurance or exhausted insurance. Medicare covers only a certain amount of Kytril, and doesn’t cover Vesanoid. If patient has any type of insurance, the program will first verify non-coverage before they fax an application. Patients are pre-screened over the phone; if they are cleared, an application is faxed to the doctor.
Initiating Enrollment	Prescriber’s office calls and pre-screening is done for each patient. Provide DEA and medical history of patient to get an application.
Health Provider’s Role	Doctor completes a section and signs the application.
Patient’s Role	Patient must fill out a section of the application and sign in two places. Income and insurance information needed, as well as proof of income.
How Dispensed	Medication is shipped to prescriber’s office.
Amount Dispensed	No more than a 3 month supply.
Refills	To get additional medications, someone from the prescriber’soffice must call for a new appliction.
Limit	Indefinitely

148. Roche Tamiflu Assistance

Pharmaceutical Company	Roche Pharmaceuticals
Program Name	Roche Tamiflu Assistance
Program Address	ot Applicable
Medicines On Program	Tamiflu
Phone Number	800-285-4484
Guidelines and Notes	This is a straight-forward one-time program. If a patient can’t afford this drug, prescriber’s office calls and a pre-screening is done. If patient meets eligibility guidelines, the company immediately faxes a coupon so the patient can get the drug at no cost. The patient should be in the office during the phone call.
Initiating Enrollment	Prescriber’s office calls upon learning that patient won’t be able to afford this drug. The patient must be present at the time of the phone call.
Health Provider’s Role	Doctor completes and signs coupon and writes prescription for patient.
Patient’s Role	Minimal information required, would be on-file already.
How Dispensed	Through pharmacy – patient takes coupon and prescription to get free drug.
Amount Dispensed	The coupon is good for a one week supply.
Refills	Not Applicable
Limit	Not Applicable

149. Roche Tasmar Program

Tasmar
Pharmaceutical Company	Roche Tasmar Program
Program Address	Roche Tasmar Program 340 Kingsland St. Nutley, NJ 07110-1199
Toll Free Phone Number	800-285-4484
Guidelines and Notes	The patient has to have no prescription drug coverage for medication requested. The patient must also have been denied Medicaid for Tasmar. This program is case managed.
Initiating Enrollment	Doctor’s office or patient can call for application. The application can only be mailed to the office. The application cannot be copied. The completed application must be mailed back.
Health Provider’s Role	Provider completes a section and sign the application.
Patient’s Role	Patient also fills out a section and sign the application.
How Dispensed	The medication is sent to doctor’s office.
Amount Dispensed	3 month supply
Refills	A new applicaiton is needed applicaiton is needed for each refill, send in 1 month before medication is used up for an uninterrupted supply.
Limit	Not specified.

150. Roche Transplant Patient Assistance Program

Pharmaceutical Company	Roche Pharmaceuticals
Program Name	Roche Transplant Patient Assistance Program
Program Address	PO Box 230547 Centreville, VA 20120
Medicines On Program	Cellcept 250 mg, Cellcept 500mg, Cellcept Oral, Zenapax 250 mg Vial
Phone Number	800-772-5790
Guidelines and Notes	They will help patients with no prescription coverage and will also help patients who have exhausted existing coverage or can’t afford the co-payments they have with their prescription coverage. The patient must be also be a US resident (or have valid visa), and must be outpatient. The company has income guidelines that they do not disclose.
Initiating Enrollment	Provider or social worker calls to give information over phone; then application is faxed to the provider or social worker. The completed application can be faxed in but the the originals must also be mailed in.
Health Provider’s Role	Doctor completes a section and sign the application. The prescription is part of application, but sure to note on the application 1 refill if needed.
Patient’s Role	The patient needs to fill a section of the application, sign it and attach proof of income.
How Dispensed	The medicine is sent to the doctor’s office.
Amount Dispensed	The medication is sent in a two month supply.
Refills	The doctor’s office calls in for another two month supply. At the end of the 4 month doctor’s office calls for a Requalification Application that is a one page document that the doctor must fill out and fax back for another 4 month supply. After a year an income documentation is needed with the Requalification Application.
Limit	Indefinitely

151. RSVP for Zyvox

Pharmaceutical Company	Pfizer, Inc.
Program Name	RSVP for Zyvox
Program Address	Not Applicable
Medicines On Program	Zyvox Tablets 600 mg
Phone Number	888-327-7787, ext 1
Guidelines and Notes	This is a new program, and going through some changes. The patient must be living in the US and being treated by a US doctor. The patient meet financial guidelines that are not disclosed. The patient can not have insurance for the medication. If the patient has exhausted their benefits or only has Medicare then they may be eligible for the the program.
Initiating Enrollment	Anyone can call to start the process, and the information will be taken over the phone.
Health Provider’s Role	Doctor or hopital staff needs to give information over the phone.
Patient’s Role	The patient needs to provide information over the phone.
How Dispensed	The patient is given a number that is taken to the pharmacy to get the medication.
Amount Dispensed	A 30 day supply is out.
Refills	After the 30 days an application is sent out to be filled out for refills.
Limit	Indefinitely

152. Rythmol Bridge Program

Pharmaceutical Company	Reliant Pharamceuticals
Program Name	Rythmol Bridge Program
Program Address	ot Applicable
Medicines On Program	Rythmol
Phone Number	800-475-2140
Guidelines and Notes	The patient must meet financial guidelines that are not disclosed.
Initiating Enrollment	The person who calls to start the process must have basic information from patient and doctor including dosage. After all the information is gathered an patient specific application will be sent to the doctor’s office.
Health Provider’s Role	The doctor must fill out a section of the application, sign and attach a prescription.
Patient’s Role	The patient must sign the application.
How Dispensed	The medication will be sent to the doctor’s office.
Amount Dispensed	A one month supply is sent, in a quantity
Refills	To get another supply another application must be fiilled out and sent in with a new prescription.
Limit	Indefinitely.

153. Safety Net Program Neupogen and Epogen

Pharmaceutical Company	Amgen, Inc.
Program Name	Safety Net Program Neupogen and Epogen
Program Address	PO Box 13185 La Jolla, CA 92039
Medicines On Program	Aranesp, Epogen, Neulasta, Neupogen
Phone Number	800-272-9376
Guidelines and Notes	This is a replacement program, so the Form C can only sent in after the patient has used the medication. The provider must be a sponsor for a patient in order for the patient to be enrolled. Once a provider has filled out a Sponsor Form (Form A) for one patient the provider doesn’t have to fill it out again for additional patients. Epogen is for dialsis patients only.(if not on dialasis contact OrthBio Tech)
Initiating Enrollment	The healthcare provider/sponsor can call for an application, it can be faxed out and the blank ones can be photocopied. Completed applications can be faxed back or mailed back.
Health Provider’s Role	Review, sign and return Patient Enrollment Form. Form B requires both the patient’s and sponsor’s signature to activate enrollment of a pre-qualified patient.
Patient’s Role	The patient must fill a section of the application and sign it.
How Dispensed	The medication is sent to the sponsor to be replaced.
Amount Dispensed	Medication is sent out in one month supplies. Form C must be used each month to get refills. Form C requires phyisican signature.
Refills	Once a year a new application must be filled out.
Limit	Indefinitely.

154. Sankyo Pharma Open Care Program

Company	Sankyo Pharma
Program Name	Sankyo Pharma Open Care Program
Program Address	PO Box 8409 Somerville NJ 08876
Medicines On Program	Benicar, WelChol
Phone Number	866-268-7327, ext 1
Guidelines and Notes	Patient must be a legal US Resident and can’t be enrolled in any public or private precription coverage programs. The patient must also be at or below 180% of the Federal Poverty Level.
Initiating Enrollment	Anyone can call to get an application automatically faxed out. The blank application can be copied. The completed application must be mailed in with the needed documents. It is very important that the patient call before sending in the paperwork.
Health Provider’s Role	Doctor completes a section, signs and attaches a prescription for a 60 day supply. Both physician and patient will receive notification about eligibility.
Patient’s Role	The patient must fill out a section of the application. And the patient must also send in proof of income with application. Once accepted the patient will recieve a letter asking them to call the company, this is another important phone call to make.
How Dispensed	The company send the medicine to doctor’s office.
Amount Dispensed	Initially they send a 2 month supply; then a three month supply is sent out.
Refills	A new application and new prescription must be sent in every time a refill is needed.(One month before current supply runs out) Once a year, the patient must call to reenroll in the program.
Limit	Indefinitely

155. Sanofi-Synthelabo Needy Patient Program

Pharmaceutical Company	Sanofi-Synthelabo Pharmaceuticals, Inc.
Program Name	Sanofi-Synthelabo Needy Patient Program
Program Address	Product Information Dept., 5th Floor 90 Park Ave. New York, NY 10016
Medicines On Program	Aralen, Danocrine, Drisdol, Hytakerol, Kerlone, Mytelase, pHisoHex, Plaquenil, Primaquine, Skelid, Uroxatral
Phone Number	800-446-6267 option 2
Guidelines and Notes	The patient must have a household income of less than 125% of the Federal Poverty Guidelines and can not be eligible for any other financial help with prescriptions. Each doctor can have only 6 patients in one year on the program. Be sure to put patient’s Social Security number on the form.
Initiating Enrollment	The doctor’s office must call for the application, it will then be faxed out. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor needs to complete and sign a section and attach prescription.
Patient’s Role	The patient does not need to sign the application but there is section that needs to be filled out with basic patient information.
How Dispensed	The medicine is sent to the doctor’s office — provide street address.
Amount Dispensed	A three month supply is sent out.
Refills	For refills, doctor writes “REFILL” boldly on the prescription and sends it in. A patient can only get medication for 6 months in a year, so s/he must be off program for 6 months to be eligible to re-apply.
Limit	Indefinitely — but only 6 months each year .

156. Santen Patient Assistance Program

Pharmaceutical Company	Santan
Program Name	Santen Patient Assistance Program
Program Address	PO Box 29094 Phoenix AR, 85038-8712
Medicines On Program	Betimol, .25%, Betimol, .5%
Phone Number	866.815.6874
Guidelines and Notes	The patient must be within guide lines that they do not make public. The patient must also be a US citizen, and cannot have any insurance.
Initiating Enrollment	The patient or doctor can call for an application it will be mailed to the doctor’s office. The blank application cannot be copied, as it has carbon paper within it. The completed application must be mailed back to the company.
Health Provider’s Role	The doctor must fill out a section of the application and sign it.
Patient’s Role	The patient must also fill out a section of the application and sign it.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The medication is sent in a six month supply.
Refills	After six months a whole new application is needed.
Limit	Indefinitely

157. Schering-Plough Commitment to Care Program

Pharmaceutical Company	Schering Plough Corporation
Program Name	Schering-Plough Commitment to Care Program
Program Address	PO Box 485 San Bruno, CA 94066
Medicines On Program	Intron-A, PEG-Intron, Rebetron Combination theray, Temodar
Phone Number	800-521-7157
Guidelines and Notes	The program does not require that patients are indigent to qualify for assistance and it is pretty much a paperless program. Patient must be a US resident and have no insurance coverage for the medication.
Initiating Enrollment	Anyone can make initial contact but they require a phone interview with the patient to assess financial need. At that point they tell patient what documentation they will need. As well insurance information and paperwork, if applicable.
Health Provider’s Role	Once the patient is enrolled, a application is sent to the doctor’s office with specific forms that are faxed back in for medication.
Patient’s Role	The patient may need to send in proof of income.
How Dispensed	Medication can be sent to doctor’s office or patient’s house. The medications are sent UPS and will be to be signed for upon delivery. The pharmacy will call the arrange delivery.
Amount Dispensed	Medication is sent out once a month for six months.
Refills	Close to the end of the month the patient must call for next month’s supply. Company will contact patient after six months to see if they are still taking the medications. After a year the company needs updated paperwork.
Limit	Unlimited, as needed.

158. Senior Patient Assitance Program

Pharmaceutical Company	Janssen Pharmaceuticals, Ortho McNeil & McNeil
Program Name	Senior Patient Assitance Program
Program Address	PO Box 221009 Charlotte, NC 28222-1009
Medicines On Program	Aciphex Tablets, Bicitra, Concerta Tablets, Dermatop, Ditropan Syrup, Ditropan Tablets, Ditropan XL, Duragesic CII, Elmiron, Flexeril Tablets, Floxin, Grifulvin V Suspension, Grifulvin V Tablets, Haldol Decanoate Injection, Haldol Injection, Levaquin Tablets, Monistat-Derm, Mycelex Troche, Neutra-Phos, Neutra-Phos-K, Pancrease Capsules, Pancrease MT Capsules, Parafon Forte DSC, PolyCitra LC, PolyCitra Syrup, PolyCitra-K, PolyCitra-K Crystals, Regranex Gel 0.01%, Reminyl Oral Solution, Reminyl Tablets, Renova, Retin-A Cream, Retin-A Gel, Retin-A Liquid, Retin-A Micro, Risperdal M-TAB, Risperdal Oral Solution, Risperdal Tablets, Spectazole Cream, Sporanox Capsules, Sporanox Oral Solution, Terazol, Terazol 3 Vaginal Cream, Terazol 7 Vaginal Cream, Testoderm, Testoderm w/ Adhesive, Tolectin DS Capsules, Tolectin Tablets, Topamax, Topamax Sprinkle Capsules, Ultram, Urispas, Vascor Tablets, Vermox Tablet
Phone Number	888.294.2400
Guidelines and Notes	This is a program that covers medication made by Janssen, McNeil, and Ortho-McNeil. The patient must first be in the TogetherRX program, which is a discount prescription medication program for people on Medicaid or Social Security due to disability. For more information on this program call 800.865.7211 or www.together-rx.com.
Initiating Enrollment	The patient calls to start the process. The majority of the application is filled out over the phone. Once the application is complete it is faxed or mailed to the patient.
Health Provider’s Role	The doctor must only provide the prescriptions.
Patient’s Role	The patient must check to make sure the information on the application is correct, sign it and attach proof of income and send it back.
How Dispensed	Once approved, the TogetherRX card is upgraded for the specific medications so that the patient can take the card to the pharmacy and get the medication free
Amount Dispensed	The card is to used once a month.
Refills	The program is a year long, after which the patient needs to call to reenroll.
Limit	Indefinitely

159. Shire US Patient Assistance Program

Pharmaceutical Company	Shire Pharmaceuticals
Program Name	Shire US Patient Assistance Program
Program Address	PO Box 698 Somerville NJ 08876
Medicines On Program	Agrylin 0.5mg, Carbatrol 200mg, Carbatrol 300mg, Ethmozine Tablets 200mg, Ethmozine Tablets 250mg, Ethmozine Tablets 300mg, Fareston 60mg, Pentasa 250mg, ProAmatine 10mg, ProAmatine 2.5mg , ProAmatine 5mg
Phone Number	908-203-0657
Guidelines and Notes	The patient must have no prescription drug coverage, or have exhaused their prescription coverage. The patient must also meet undisclosed guidelines. Company also has a cost-share program for patients who don’t meet the eligibility guidelines for assistance. If patient has run out of prescription coverage they will need to get a letter stating so from their insurance company. If patient has Medicare only, they will need to provide a copy of their Medicare card and a written statement saying they have no prescription coverage.
Initiating Enrollment	Only doctors office can call for an application, which is patient specific. The application is then faxed to the doctor’s office. The completed application must be mailed back.
Health Provider’s Role	Doctor completes a section, signs and attaches a prescription.
Patient’s Role	The patient must fill out a section of the application, sign it and attachment proof of income. See above for other possible attachment needs.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	90 day supply.
Refills	Physician obtains Reorder Form that must be signed by physician and patient, attaches new prescription, and mails in. Once a year a whole new application is needed.
Limit	Indefinitely

160. Solvay Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	Solvay Pharmaceuticals, Inc.
Program Name	Solvay Pharmaceuticals Patient Assistance Program
Program Address	C/O Express Scripts Speciality Distribution Svc. PO Box 66550 St. Louis MO 63166-6550
Medicines On Program	Aceon Tablets 2 mg, Aceon Tablets 4 mg, Aceon Tablets 8 mg, Creon Minimicrospheres DR 10 mg, Creon Minimicrospheres DR 20 mg, Creon Minimicrospheres DR 5 mg, Estratest H.S., Estratest Tablets, Rowasa Enema 4g/60ml
Phone Number	800-256-8918
Application	Click here Solvay Pharmaceuticals Patient Assistance Program to download PDF
Guidelines and Notes	The patient must be a US resident, have no medical insurance, and be medically indigent to qualify for this program. The patient’s annual household income minus the out of pocket medical expenses must be under financial guidelines that the company does not disclose.
Initiating Enrollment	Anyone can call for the application and it will be faxed out. The completed form must be submitted directly from prescriber’s office either by fax or mail.
Health Provider’s Role	A licensed practitioner or nurse practitioner or physician’s assistant must fill out a section of the application and sign the application.
Patient’s Role	The patient must provide number in household, amount of household income and out of pocket medical expenses. Patient signature not required.
How Dispensed	The medication is shipped via Priority Mail to the doctor’s office.
Amount Dispensed	The medication is sent out in a 3 month supply, except for Rowasa which is sent in a 6 week supply.
Refills	To obtain a refill send in a new application.
Limit	Indefinitely

161. Solvay Pharmaceuticals, Inc./Unimed Patient Assistance Program

Pharmaceutical Company	Solvay Pharmaceuticals, Inc./Unimed
Program Name	Solvay Pharmaceuticals, Inc./Unimed Patient Assistance Program
Program Address	PO Box 66550 St. Louis MO 63166
Medicines On Program	Anadrol-50, Androgel, Marinol
Phone Number	800-256-8918
Guidelines and Notes	The patient must be a US resident, meet the income requirements which they don’t disclose and have no insurance coverage for the requested medication.
Initiating Enrollment	Anyone can call for the application, it will be faxed out. The completed application must faxed back from the doctor’s office or mailed in.
Health Provider’s Role	Doctor completes a section and signs, and writes a prescription for up to six months worth of medication. Different application is needed for each drug.
Patient’s Role	Patient completes income and insurance information, proof of income is also required. Patient is also requested to include a copy of insurance card if applicable.
How Dispensed	The medication can be shipped to the doctor’s office or the patient’s home but there must be someone to sign for the shippment. (Shipped Federal Express.)
Amount Dispensed	Up to a 90 day supply is sent out at one time.
Refills	For refills the patient calls for a refill, after six (when the prescription is done) the doctor sends in a new prescription. After a year a whole new application is needed.
Limit	Indefinite

162. SP-Cares

Pharmaceutical Company	Schering Plough Corporation
Program Name	SP-Cares
Program Address	PO Box 52122 Phoenix, AZ 85072
Medicines On Program	Clarinex Tablets, diprolene Gel, diprolene Lotion, diprolene Ointment, Elocon Cream, Elocon Ointment, imdur 60, imdur Tablets, K – Dur 10, k – dur 20, Lotrisone Cream, Lotrisone Lotion, nasonex, Nitro – Dur patches .1, Nitro – Dur patches .6, Proventil aerosol inhaler , Proventil HFa INHALER
Phone Number	800-656-9485
Guidelines and Notes	This is a program for Schering-Plough allergy, asthma, dermatology and cardiovascular prescription products. The medication list is always changing, and the company doesn’t publish a list. Call for a specific medication. The patient must be under federal poverty level, but the specific financial guidelines are not disclosed. Also, if patient has no income, then a physician’s or social worker’s letter verifying this must be included with the application. If patient is denied assistance and extenuating circumstances exist, physician should call.
Initiating Enrollment	Doctor’s office or patient can call to request form or can download it from www.schering-plough.com, click on the “Corporate Responsibility” The completed application must be mailed back in with the prescription.
Health Provider’s Role	The doctor needs to fill out a section and sign the application.
Patient’s Role	The patient must also fill out a section and attach proof of documentation for all the members of the household. The patient also needs to the sign the application.
How Dispensed	Sends medicine to doctor’s office (it can take 4-6 weeks.)
Amount Dispensed	The medication will be sent in upto a 3 month supply.
Refills	When the approval letter is sent a reorder form is included. This form is needed to get refills. After a year, a whole new application is needed with documentation.
Limit	Indefinitely

163. Specialty Distribution Services Program for Generic Medications

Pharmaceutical Company	E Specialty Distribution Services
Program Name	Specialty Distribution Services Program for Generic Medications
Program Address	PO Box 66536 St Louis, MO 63166-6536
Medicines On Program	atenolol 100 mg, atenolol 25 mg, atenolol 50 mg, lisinopril 10mg, lisinopril 20mg, lisinopril 30mg, lisinopril 40mg, lisinopril 5mg, omeprazole 10 mg, omeprazole 20 mg
Phone Number	866-479-3472
Guidelines and Notes	This is a program to help patients get 3 generic medications at a discount. The patient must attach payment with the application. For Atenolol the cost is $15 for a 90 day supply. For Lisinopril $20 for a 90 day supply,for Omepraz $40 for a 90 day supply, for Benazepril $25 for a 90 day supply, and Benazepril HCT $25 for a 90 day supply.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. The blank application can be copied. The completed application must be mailed back.
Health Provider’s Role	The doctor must fill out a section and sign. There is a section on the application that serves as a perscription.
Patient’s Role	The patient must fill out a section, sign and attach the payment
How Dispensed	The medication is sent to the patient’s house.
Amount Dispensed	A 90 day supply is sent.
Refills	A new perscription and payment is needed for refills. After one year a whole new application is needed.
Limit	Indefinitely

164. Star Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	Starr Pharamceuticals, Inc.
Program Name	Star Pharmaceuticals Patient Assistance Program
Program Address	1881 W State. Rd 84, Suite 101 Fort Lauderdale, FL
Medicines On Program	Porsed/DS
Phone Number	800-845-7827
Guidelines and Notes	This is a fairly informal program. There are certain guidelines that are not disclosed.
Initiating Enrollment	The doctor’s office should call with patient’s basic information and dosage information. An application is then sent to the doctor’s office to complete.
Health Provider’s Role	The doctor must fill out a section of the applicaiton. A prescription is also needed.
Patient’s Role	The patient must provide information and proof of income.
How Dispensed	The medication is sent directly to the doctor’s office.
Amount Dispensed	The medication is sent in a bottle of 100 tablets.
Refills	The company will contact the doctor’s office about refills and reapplications.
Limit	Indefinitely

165. Stiefel Laboratories Patient Assistance Program

Pharmaceutical Company	Stiefel Laboratories
Program Name	Stiefel Laboratories Patient Assistance Program
Program Address	6340 Sugarloaf Parkway, Ste 400 Duluth, GA 30097
Medicines On Program	Brevoxyl Cleansing Lotion, Brevoxyl Creamy Wash, Brevoxyl Hydrophase Gel 4%, Brevoxyl Hydrophase Gel 8%, Clindents, Sulfoxyl Lotion, Zetacet Lotion, Zetacet Topical Gels
Application	Contact program for application
Guidelines and Notes	The patient needs to have no insurance for prescription drugs or Medicaid reimbursements. The patient met financial guildelines that are not disclosed.
Initiating Enrollment	The provider should call the company for an application which can be faxed out. The blank application can also be copied. The completed application should be mailed back to the company.
Health Provider’s Role	The provider must fill the application and attach a prescription.
Patient’s Role	The patient only needs to tell the provider s/he is in need.
How Dispensed	The medication is sent to the provider’s office.
Amount Dispensed	A three month supply is sent out per quarter per patient.
Refills	After three months a new application and perscrition is needed.
Limit	Indefinitely

165. Sucraid Patient Assistance Program

Sucraid
Pharmaceutical Company	Sucraid Patient Assistance Program
Program Address	Sucraid Patient Assistance Program C/O NORD PO Box 1968 Danbury, CT 06813-1968
Toll Free Phone Number	800.424.9002
Guidelines and Notes	Patients must be US citizens or permanent residents. Each case is reviewed individually, but is based on patient’s income and lack of perscription coverage.The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.
Initiating Enrollment	Anyone can call to start the process, and after some phone screening, an application is sent.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section and sign the application.
How Dispensed	The medication is sent to the patient’s home.
Amount Dispensed	The amount sent depends on the need of the patient and the amount awarded.
Refills	A new application is needed every year.
Limit	Indefinitely

166. SuperGen Patient Assistance Program

Pharmaceutical Company	SuperGen
Program Name	SuperGen Patient Assistance Program
Program Address	PO box 220368 Charlotte NC, 28211-0368
Medicines On Program	Mitomycin, Nipent, 10 mg vial
Phone Number	800-340-8667
Guidelines and Notes	Patient must be a US resident, and meet income requirements that are not disclosed. The patient must also be uninsured for the medications. The current application has only “Nipent” at the top, but can be used for both medications.
Initiating Enrollment	Anyone can call for the application, which would be faxed to the doctor. The completed application can be faxed or mailed.
Health Provider’s Role	The doctor must fill out section, sign and attach prescription.
Patient’s Role	The patient must fill out a setion, sign and attach proof of income.
How Dispensed	The medications are sent to the doctor’s office.
Amount Dispensed	A 30 day supply is sent.
Refills	The company calls the doctor’s office to start the refill process. After a year a new application is needed.
Limit	Indefinitely

167. SUPPORT Program for Crixivan

Pharmaceutical Company	Merck & Company , Inc.
Program Name	SUPPORT Program for Crixivan
Program Address	PO Box 222137 Charlotte, NC 28222-2137
Medicines On Program	Crixivan
Phone Number	800-850-3430
Guidelines and Notes	The patient must be a US resident and have no prescription insurance or have reached the cap for the year. The patient must also meet financial guidelines that are not disclosed.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. The blank application can be copied. The application must be mailed back FAXED.
Health Provider’s Role	Doctor must complete a section and sign. The doctor must also attach a prescription. The prescription should be written for 90 days.
Patient’s Role	The patient must provide income and insurance information and sign the application.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A supply for 3 months is sent out at one time.
Refills	For refills the company will fax the doctor for a new prescription. After one year a new application is needed.
Limit	Indefinitely

168. Synvisc Reimbursement Hotline

Pharmaceutical Company	Genzyme Corporation
Program Name
Program Address	33 Morehall Road Fracer, PA, 19355
Medicines On Program	Synvisc
Application	Contact program for application
Guidelines and Notes	Synvisc is for osteoarthritis of the knee. Patient’s must be a US resident and have no insurance. The patient must also be less than 200% of the Federal Poverty Level.
Initiating Enrollment	Someone from the doctor’s office call the company for prescreening over the phone. They also need to provide medical and insurance information for the patient. If the patient passes the prescreening, then application is sent to the doctor’s The completed application is mailed back to the company address on the application.
Health Provider’s Role	The doctor’s office must fill out a section and sign the application.
Patient’s Role	The patient must fill a section. Proof of income is also required.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	Up to two kits. One kit per knee.
Refills	To reapply after six months start the process over. A patient is limited to up to two kits within six months.
Limit	Undetermined

169. Takeda Pharmaceuticals America Patient Assistance Program

Pharmaceutical Company	Takeda Pharmaceuticals America
Program Name	Takeda Pharmaceuticals America Patient Assistance Program
Program Address	C/o SDS PAP – TAK Customer Service PO Box 66552 St. Louis, MO 63166
Medicines On Program	Actos
Phone Number	800-830-9159
Guidelines and Notes	Income guidelines based on poverty; patient’s household must be under 300% of federal poverty guidelines. Patient must be a legal US Citizen with no prescription coverage and not be eligible for Medicaid. It normally takes 2-3 buisness days to process application. And if approved the medication will arrive in roughly 10 days.
Initiating Enrollment	Anyone can call to get an application faxed out. The blank application can be copied. The completed application and prescription can be faxed back but needs to arrive with an office cover or banner printout.
Health Provider’s Role	Doctor completes practitioner information, signs and dates it, and writes a prescription for 90 day supply. The medication is only offered in 90 tablet bottles.
Patient’s Role	Patient completes information on income and insurance and signs and dates the form. (If the patient can not sign then only the person with power of attorney can sign for them)
How Dispensed	The medication is sent out to the patient via Postal Service.
Amount Dispensed	The medication is sent out in a 90 day supply.
Refills	A Reorder mailer is sent with medication. The patient must get a new prescription and mail it in before current supply runs out. After one year a whole new application is required.
Limit	Indefinitely.

170. TOBI Foundation

Pharmaceutical Company	Chiron Corporation
Program Name	TOBI Foundation
Program Address	250 Technology Park Lake Mary, FL 322746
Medicines On Program	TOBI
Phone Number	877.TOBI 4 CF
Guidelines and Notes	The patient must be a US resident, with a confirmed diagnosis of CF. Applicants must meet income guidelines that are not disclosed.The applicants are expected to have applied to and been denied state and federal aid programs. Applicants with some insurance must have a co-payment, co-insurance or deductible of $25 per carton for TOBI.
Initiating Enrollment	Anyone can start the process by call the above number for an application or by going to the website www.TOBIfoundation.org. The application has three sections: Patient Consent Form, Physician Attestation Form and Patient Application. (8 pages total) The completed application can be faxed back.
Health Provider’s Role	The physician must fiill out and sign the Physician Attestation Form.
Patient’s Role	The patient must sign the Patient Consent Form, and Application and provide proof of income.
How Dispensed	Once approved, the Foundation sends a voucher to a participating CF Services Pharmacy. The patient must contact the pharmacy to get the medication.
Amount Dispensed	The amount sent is amount needed.
Refills	The company works with the CF Services Pharmacy to get refills sent out. Once a year a new application is needed.
Limit	Not Applicable

171. Upsher-Smith Patient Assistance Program

Pharmaceutical Company	Upsher-Smith
Program Name	Upsher-Smith Patient Assistance Program
Program Address	PO Box 66554 St Louis, MO 63166
Medicines On Program	Folgard Rx 2.2 Tablets, Klor-Con, Pacerone
Phone Number	866-851-2826
Guidelines and Notes	The patient must be US citizen and have no prescription insurance. The patient must also meet financial guidelines that are not disclosed.
Initiating Enrollment	Anyone can call for an application and it will automatically be faxed out. The blank application can copied.
Health Provider’s Role	The doctor must fill out a section of the application and sign it.
Patient’s Role	The patient must also fill out a section of the application
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	A maxium of two bottle is sent.
Refills	Patient can get one refill with a new application.
Limit	After two shipments patient is no longer eligible

172. Valeant Pharmaceuticals International Patient Assistance Program

Pharmaceutical Company	Valeant Pharmaceuticals International
Program Name	Valeant Pharmaceuticals International Patient Assistance Program
Program Address	3300 Hyland Ave. Costa Mesa, CA 92626
Medicines On Program	8-MOP capsules 10mg, Ancobon Capsules, 250 mg, Ancobon Capsules, 500 mg, Benoquin Cream, 1/4 oz, Efudex Cream 5%, 25 gram, Efudex Solution 2%, 5ml, Efudex Solution 5%, 10 ml, Eldopaque 2% Cream, 1 oz, Eldopaque 2% Cream, 1/2 oz, Eldopaque Forte 4% Cream, 1 oz, Eldoquin 2% Cream, 1 oz, Eldoquin 2% Cream, 1/2 oz, Eldoquin Forte 4% Cream, 1oz, Fototar Cream, 3oz, Glyquin 4% Cream, Glyquin XM 4% Cream , Mestinon, 180 mg, Mestinon, 60mg, Mestinon Syrup, 16 oz, Oxsoralen lotion, Oxsoralen-Ultra Capsules, 10mg, Prostigmin 15 mg Tabs, RV Paque Cream, Solaquin 2% Cream , Solaquin Forte 4% cream, Solaquin Forte 4% Gel, Vitadye 4 pack vials, 8 gram, Vitadye Lotion
Phone Number	Not Applicable
Guidelines and Notes	The patient must have applied to Medicaid and been denied. The patient must be at or below 200% of the Federal Poverty Guidelines and have no prescription coverage. There is a limit of one medication per application except for Mestinon patients.
Initiating Enrollment	The company prefers that a completed application is sent in to start the process. If a application is needed, write the company for an application. The blank application can be copied. The completed application should be mailed in.
Health Provider’s Role	The doctor must fills out a section of the application, sign and attach a prescription.
Patient’s Role	The patient needs to fill out a section of the application and sign. The patient must also attach proof of income, proof of no insurance and a Medicaid denial letter.
How Dispensed	The medication is sent to the doctor’s office. Mestinon can be shipped directly to the pharmacy.
Amount Dispensed	The maximum amount sent out for any medication is 3 months, see the application for specifics about how much is given for each medication per a 3 month period.
Refills	A Reorder Form needs to be filled out and send back for a refill. Once a year a new application, with documentation is needed.
Limit	Indefinitely

173. Wellspring Patient Assistance Program

Pharmaceutical Company	Wellspring
Program Name	Wellspring Patient Assistance Program
Program Address	PO Box 801 Somerville NJ, 08876
Medicines On Program	Dibenzyline, Dyrenium
Phone Number	908.203.3791
Guidelines and Notes	The patient has to be within income guidelines that they don’t disclose. And the patient must have no prescription coverage, have reached their cap or their insurance company pays less than 25% of prescription costs. If the patient is enrolled in Medicaid, send in proof of Medicaid status.
Initiating Enrollment	Someone from the doctor’s office calls to start the process, need to give doctor’s DEA number, office address and patient’s demographic. The company will fax out patient specific application. The completed application has to be mailed back.
Health Provider’s Role	Doctor has to fill out a section and sign and attach a prescription.
Patient’s Role	The patient needs to fill out a section and sign it. The patient must also provide proof of income and insurance verification (depending on the insurance.) Patient with Medicaid must send proof of status every three months.
How Dispensed	The medication is sent to the doctor’s office.
Amount Dispensed	The medication is sent in a three month supply.
Refills	When the patient gets to the last bottle of medication s/he should tell the doctor’s office and the office must call for a refill. Once a year a whole new application with documentation is needed.
Limit	Indefinitely

174. NABI Reimbursement Program for WinRho

Pharmaceutical Company	NABI Biopharmaceuticals
Program Name	NABI Reimbursement Program for WinRho
Program Address	PO Box 22157 Charlotte, NC 28222-2157
Medicines On Program	WinRho SDF
Phone Number	800-789-2099
Guidelines and Notes	They will help as long as this is used for ITP non-splenectomized (the FDA approved use) The patient must be US citizen, with no medical insurance. If there is medical insurance, the company will verify benfits. The patient must fit within in house income guidelines which they don’t disclose. This is not a replacement program, so the patient should be enrolled before starting the medicaion.
Initiating Enrollment	Anyone from the doctor’s office can call to register patient by phone, then an application sent. Application is patient speciifc and must be mailed back.
Health Provider’s Role	Doctor completes and signs a section of the application. A prescription is part of application.
Patient’s Role	The patient must provide detailed financial and insurance information needed, provide proof of income, and sign the application.
How Dispensed	The medication is sent to doctor’s office.
Amount Dispensed	As much as needed, there is no guidelines for the amount.
Refills	A new application is needed every 6 months, but proof of income is only needed once a year.
Limit	Indefinite

175. Wyeth Pharmaceutical Patient Assistance Foundation

Pharmaceutical Company	Wyeth Pharmaceuticals
Program Name	Wyeth Pharmaceutical Patient Assistance Foundation
Program Address	PO Box 1759 Paoli, PA 19301-0859
Medicines On Program	Cordarone Tablets 200 mg, Effexor Tablets 100 mg, Effexor Tablets 25 mg, Effexor Tablets 37.5 mg, Effexor Tablets 50 mg, Effexor Tablets 75 mg, Effexor XR Capsules 150 mg, Effexor XR Capsules 37.5 mg, Effexor XR Capsules 75 mg, Inderal LA Capsules 120 mg, Inderal LA Capsules 160 mg, Inderal LA Capsules 60 mg , Inderal LA Capsules 80 mg, Inderal Tablets 10 mg, Inderal Tablets 20 mg, Inderal Tablets 40 mg, Inderal Tablets 60 mg, Inderal Tablets 80 mg, Inderide Tablets 40/25 mg, Inderide Tablets 80/25 mg, Lodine Capsules 200 mg, Lodine Capsules 300 mg, Lodine Tablets 400 mg , Lodine Tablets 500 mg, Lodine XL Tablets 400 mg, Lodine XL Tablets 500 mg, Lodine XL Tablets 600 mg, Materna, Minocin Capsules 100 mg, Minocin Capsules 50 mg, Oruvail Capsules 200 mg, Oruvail Capsules ER 200 mg, Phenergan suppositories 12.5 mg , Phenergan suppositories 25 mg , Phenergan suppositories 50 mg, Phenergan tablets 25 mg , Phenergan tablets 50 mg, Phenergan tablets12.5 mg, Phospholine Iodide 6.25mg per 5ml, Premarin tablets 0.3 mg, Premarin tablets 0.625 mg, Premarin tablets 0.9 mg, Premarin tablets 1.25 mg, Premarin tablets 2.5 mg, Premarin Vaginal Cream 0.625 mg, Premphase 0.625/5mg, Prempro 0.3/1.5mg, Prempro 0.45/1.5 mg, Prempro 0.625/2.5mg, Prempro 0.625/5 mg, Protonix Tablets 40 mg, Trecator-SC Tablets 250 mg
Phone Number	800-568-9938
Guidelines and Notes	This program is for patients who are US residents, do not have other sufficient financial resources to pay for the medication or if s/he is paying for the medication would cause a severe hardship. Patients meet the following financial guidelines- at or under 17,960 for a family of one at or under 24,240 for a family of two at or under 30,520 for a family of three.
Initiating Enrollment	Form can be automatically faxed by calling above number. Application can be copied. Competed form must be mailed and all signatures on the form must be original. There are two pages to the application, the form and the patient consent form. There are also two pages of explanation and a list of the drugs they carry.
Health Provider’s Role	The licensed practioner must fill out a section and sign it.
Patient’s Role	The patient must provide minimal financial information required along with basic identifying information and sign the application.
How Dispensed	The company sends medicine to doctor’s office. Takes about 4-6 weeks for processing.
Amount Dispensed	A three month supply is sent.
Refills	Every three months the patient and practioner must fill out another application.
Limit	Indefinitely

176. Xanodyne Pharmacal Patient Assistance Program

Pharmaceutical Company	Xanodyne Pharmacal, Inc.
Program Name	Xanodyne Pharmacal Patient Assistance Program
Program Address	7300 Turfway Road, #300 Florence, KY 41042
Medicines On Program	Amicar Injection, 5 gm, 20 ml vial, Amicar Syrup, 250 mg/ml 16 fl.oz, Amicar Tablets, 500 mg
Phone Number	877-926-6396
Guidelines and Notes	The patient must be a US resident who meet financial guidelines that are not disclosed. Be sure it is completed with all required attachments and signatures; they will not process an incomplete application. They recommend making a copy of the completed application for records.
Initiating Enrollment	Anyone can call for an application it can be faxed out. The completed application can be faxed or mailed back to the company.
Health Provider’s Role	The physician must fill out a section, sign and attach a copy of her/his most recent State Board of Medicine Licensure.
Patient’s Role	The patient must fill out a section of financial and insurance information, sign and attach documentation of family income.
How Dispensed	The medication is sent to the doctor.
Amount Dispensed	A three month supply is sent out.
Refills	A new application is needed every three months.
Limit	Unspecified

177. Xcel Pharmaceuticals Patient Assistance Program

Pharmaceutical Company	Xcel Pharmaceuticals
Program Name	Xcel Pharmaceuticals Patient Assistance Program
Program Address	PO Box 430 Hackettstown, NJ 07840
Medicines On Program	DHE 45, Diastat 10mg, Diastat 15mg, Diastat 2.5 mg, Diastat 20 mg, Diastat 5 mg, Migranal 4 mg, Mysoline 250 mg, Mysoline 50 mg
Phone Number	800-511-2120
Guidelines and Notes	The patient’s income must be at or below 200% of the Federal Poverty Guidelines. The patient may be asked to apply to Medicaid before getting help. They provide case management to help patients find programs for which they made be qualified.
Initiating Enrollment	Someone from the doctor’s office can call to get an application faxed out, but they prefer to have the application done electronically on rxhope.com. The completed application can be faxed back.
Health Provider’s Role	Phyisican needs to provide basic information and sign the application.
Patient’s Role	The patient needs to provide basic information about dependants, income and insurance.
How Dispensed	Medication is sent to the doctor’s office
Amount Dispensed	Each medication is different. Migranal: 4 nasal sprays, Diastat: 2 syringes, DHE 45: 10 unit and Mysoline is sent in a three month supply.
Refills	A new application is needed for each refill.
Limit	Indefinitely

178. Xigris

Pharmaceutical Company	Eli Lilly & Company
Program Name
Program Address	ot Applicable
Medicines On Program	Xigris
Phone Number	877-522-4357
Guidelines and Notes	This program is for medication replacement, usually the patient is an in-patient at a hospital. The company prefers someone from the hospital call to start the process. The health care provider, pharmacist, or social worker must be first be enrolled in the program before enrolling patients. To enroll go to www.xigris.com and follow the directions. Once the application is complete, print it out and fax to the company. They will notify when the application is processed.
Initiating Enrollment	To enroll a patient go to www.xigris.com and get a patient application. It will lead you through the steps. Or call the above number and the company will get your an application. The completed application should be printed and faxed in. The company will call and send letters if the patient is accepted.
Health Provider’s Role	Not Applicable
Patient’s Role	The patient just needs to tell someone that they are in need.
How Dispensed	The medication is sent to the hospital.
Amount Dispensed	The amount sent is however much was used.
Refills	Not Applicable.
Limit	Unclear

179. Zetia Patient Assistance Program

Pharmaceutical Company	Merck & Company , Inc.
Program Name	Zetia Patient Assistance Program
Program Address	PO Box 365 Horsham, PA 19044-0365
Medicines On Program	Zetia
Phone Number	800-347-7503
Guidelines and Notes	The program is only available to patients who live in the US and have a prescription for the medication from a US-licensed doctor. The patient cannot have any insurance coverage and have an income at or below $18,000 for an individual and #24,000 for a couple.
Initiating Enrollment	Applications can only be sent to persons over the age of 18, but anyone can call for the application. The application sent in must be an original, it can not be copied. The completed application must be mailed in.
Health Provider’s Role	The physician must fill out two sections, one of which is a prescription built into the application. The physician must also sign the application (no stamps accepted.) The prescription should be made out for a 90 day supply with 3 refills.
Patient’s Role	The patient must fill a section that include questions about annual household income, insurance and sign the application.
How Dispensed	The medication can be sent to the physicians office or the patient’s home.
Amount Dispensed	A 90 day supply is sent out.
Refills	To get the refills, someone must call the company. After one year a new application is needed.
Limit	Indefinitely

180. Zevalin Results

Pharmaceutical Company	BAgen168en IDEC, Inc
Program Name	Zevalin Results
Program Address	PO Box 222007 Charlotte, NC 28222-2007
Medicines On Program	Yttrium-90 Zevalin Kit, Zevalin Kit-Indium-111
Phone Number	800.386.9997
Guidelines and Notes	This program helps both patients who are uninsured and those who are insured. For the insured patient, the company will help with billing, claims and appeals. For patients who are uninsured the company will provide medication for qualified patients. The patient must be a US resident and meet financial guidelines that are not disclosed. The patient must also not qualify for any government programs. If the patient qualifies for the program, they must still pay for the medication for the test infusion (Indium-111) but not the kit.
Initiating Enrollment	Anyone can call for an application and it will be faxed out. The application can be copied. The completed application should be faxed back to the company.
Health Provider’s Role	The doctor must fill out a section and sign the application.
Patient’s Role	The patient must fill out a section about insurance and financial information and sign the application.
How Dispensed	A shipment is sent to the radiopharmacy of choice. (If the patient is insured but is denied coverage then the site is sent a credit.)
Amount Dispensed	One kit is sent out for the Indium-111 Zevalin (but not the radoisotope.) and one kit Yttrium-90 Zevlin and 50 mCi Yttrium-90 for preperation for the Yttrium. (This enough for one dosage.)
Refills	This is one time medication. There is no reapplication.
Limit	N/A

181. Zyprexa Patient Assistance Program

Pharmaceutical Company	Eli Lilly & Company
Program Name	Zyprexa Patient Assistance Program
Program Address	PO Box 230999 Centerville, VA 20120
Medicines On Program	Zyprexa, Zyprexa Zydia
Phone Number	800-488-2133
Guidelines and Notes	The patient must meet financial guidelines that are not disclosed and be a US resident. Company reimbursement specialists will assist with finding a payment source. Program is designed to provide temporary assistance until other resources can be found.
Initiating Enrollment	Someone from the doctor’s office must call for the application. It will be faxed. This blank application can be copied. The completed application should be mailed back.
Health Provider’s Role	The provider fills out a section and signs the application.
Patient’s Role	The patient must fill out a section of the application and sign the application The patient may need to provide proof of denial from insurance companies.
How Dispensed	The medication is sent to physician
Amount Dispensed	Medication is sent ouf in four month supply
Refills	After four months an entirely new application is needed.
Limit	Indefinite

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January 1, 1970

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_________ and I will pay you $5.00 for it.” The scammer has a few options here. They can simply take the money, write an article and send it to the victim. The victim is none the wiser. The scammer can write a completely bogus article and send it to the victim. The victim is none the wiser. The scammer can write an article, but make it completely worthless. The victim is none the wiser. The scammer can write an article, but make it so poorly written that the victim knows it is worthless. The victim is none the wiser. The scammer can write an article and make it so poorly written that the victim

January 1, 1970

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___________?” and “Do a guest post for my blog on the keyword ___________.” This is the exact same thing. The only difference is that you’re asking them to do you a favor instead of offering to do them a favor. Again, this is a very effective strategy because it’s a win-win situation. You’re offering to do something that they want you to do, so they’ll be more inclined to respond to you. 2. Be specific When you’re writing your outreach email, it’s important to be as specific as possible. This is because you want to make

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January 1, 1970

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__________.” 3. Do not use “the” in your title. 4. Use your keyword in the title. 5. Use your keyword in the body of the article. 6. Use your keyword in the title of your blog post. 7. Use your keyword in the URL of your blog post. 8. Use your keyword in the title of your blog post. 9. Use your keyword in the body of your blog post. 10. Use your keyword in the title of your blog post. 11. Use your keyword in the body of your blog post. 12. Use your keyword in the title of your blog post

January 1, 1970

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__________. I need a good writer to write an article for the keyword _________. I need a writer to write an article for the keyword _________. I need a good article written for the keyword _________. I need a good article written for the keyword _________. I need an article written for the keyword _________. I need an article written for the keyword _________. I need an article written for the keyword _________. I need an article written for the keyword _________. I need an article written for the keyword _________. I need an article written for the keyword _________. I need an article written for

January 1, 1970

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_________ and I’ll pay $50 for it.” Or, “I’ll pay $50 to the first person who can fix my computer.” Or, “I’ll pay $50 to the first person who can fix my computer AND write me an article.” Or, “I’ll pay $50 to the first person who can fix my computer AND write me an article AND make me a video.” Or, “I’ll pay $50 to the first person who can fix my computer AND write me an article AND make me a video AND design me a logo.” Or,

January 1, 1970

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_________”. Using this strategy, I was able to get a lot of high-quality backlinks to my website. I also started to target more long-tail keywords. Long-tail keywords are keywords that are more specific and less competitive. For example, the keyword “social media” is very competitive and gets a lot of searches each month. But “how to grow your Instagram following” is a more specific and less competitive keyword. I started to include more long-tail keywords in my articles and posts. This was a great way to get more traffic to my website. I also started to use the Facebook Ads to promote my posts.

January 1, 1970

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January 1, 1970

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_________” and then fill in that blank with the keyword for which you want to write. That’s it. You’re done. Now, you just need to go back to your keyword research and find another keyword to write about. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another. And another.

January 1, 1970

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Repvacancy

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January 1, 1970

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________. I will pay you $15 for 500 words.” You can also use the keyword “write my article” or “article writing” but I have found that people who are looking for someone to write their article are more likely to respond to the keyword “write my article”. I have found that this is a great way to get new clients and to build up your portfolio of work. The great thing about writing articles is that you can write them in your own time. You can write them in the evenings or at the weekend. You can use a keyword tool to see what the most popular keywords are for the article you are writing. When you have

January 1, 1970

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__________. Please provide a list of 3-5 keywords related to __________. Please check my site and provide me with your suggestions. Please check my articles and let me know what you think about them. Please check out my site and let me know what you think about it. Please check out my website and let me know what you think about it. Please check out this page and let me know what you think about it. Please check out this site and let me know what you think about it. Please check out this website and let me know what you think about it. Please check out this website and let me know what you think of it

January 1, 1970

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