MEDICAL
CARE PRESCRIPTION
ASSISTANCE |
GENENTECH,
INC. GENETICS INSTITUTE, INC. GENZYME CORPORATION GILEAD SCIENCES, INC. GLAXOSMITHKLINE HOECHST MARION ROUSSEL, INC. IMMUNEX COROPORATION JANSSEN PHARMACEUTICA JANSSEN PHARMACEUTICA KNOLL PHARMACEUTICAL COMPANY LEDERLE LABORATORIES MERCK & CO., INC. - Aggrastat (tirofiban HCI) NEA CLINIC NEUMEGA NOVARTIS PHARMACEUTICALS ONCOLOGY ACCESS TO CARE PROGRAM ORGANON INC. ORTHO BIOTECH INC. ORTHO DERMATOLOGICAL ORTHO-McNEIL PHARMACEUTICAL, INC. OTSUKA AMERICA PHARMACEUTICAL, INC. PARK-DAVIS PFIZER INC. PHARMACIA CORPORATION PRESCRIPTION ASSISTANCE LINE FOR SENIORS PROCTER & GAMBLE PHARMACEUTICALS, INC. RHONE-POULENC RORER INC. ROCHE LABORATORIES, INC. ROXANE LABORATORIES, INC. SANDOZ PHARMACEUTICAL CORPORATION SANKYO PHARMA SANOFI-SYNTHELABO INC. SCHERING LABORATORIES/KEY PHARMACEUTICALS SEARLE SERONO LABORATORIES, INC. SIGMA-TAU PHARMACEUTICALS, INC. STATE AND FEDERAL ASSOCIATES THE LIPOSOME COMPANY, INC. THE SUPPORT PROGRAM FOR CRIXIVAN TAKEDA PHARMACEUTICALS AMERICA WYETH-AYERST LABORATORIES |
| Medical Care | |
BOSTON
MOUNTAIN RURAL HEALTH CENTER, INC. back to top ^ Other Program Information: |
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CABUN
RURAL HEALTH SERVICES, INC. back to top ^
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COMMUNITY HEALTH CENTERS OF ARKANSAS, INC. back to top ^
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CORNING AREA HEALTH CARE, INC. back to top ^
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EAST
ARKANSAS FAMILY HEALTH CARE, INC back to top ^
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JEFFERSON COMPREHENSIVE CARE SYSTEM, INC. back to top ^
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LEE COUNTY COOPERATIVE CLINIC, INC. back to top ^
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MAINLINE HEALTH SYSTEMS, INC. back to top ^
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MID-DELTA HEALTH SYSTEMS back to top ^
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WEST ARKANSAS TOTAL COMMUNITY HEALTH, INC. back to top ^ |
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| WHITE RIVER RURAL HEALTH CENTERS, INC. back to top ^ P.O. Box 497 623 West 9th Street Augusta AR 72006 Telephone #: 870-347-253 Fax: 870-347-288 Counties: Woodruff Jackson Monroe White Prairie Cross Lonoke Other Program Information: Member of Medical Health Centers of Arkansas, Inc. Ray Cockrill, Executive Director; Gary Eads, Assistant Executive Director; Dr. Steven Collier, Clinical Director (Private Office PO Box 277/ 347-2568 Brenda). Bald Knob Medical Clinic; Carlisle Medical Clinic; Cotton Plant Medical Clinic; Des Arc Medical Clinic; Hazen Medical Clinic; McCrory Health Center; Swifton Medical Clinic; Parkin Clinic; Kensett Clinic; Newport Clinic; Wynne Health Center |
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| Prescription Assistance | |
| ABBOTT
LABORATORIES back to top ^ Product Covered: Most Abbott Lab Pharmaceutical Products Uninsured Patient Program 200 Abbott Park Road, D31C Abbott Park, IL 60064-6163 Toll Free #: (800) 222-6885 Counties: All Arkansas Counties Eligibility: Abbott Laboratories patient assistance program is available to outpatients who do not have insurance reimbursement for prescriptions and are not eligible for governmental assistance programs (i.e., Medicaid, ADAP). Other Program Information:The licensed prescribers office contacts Abbott Laboratories to request an application on the behalf of a patient. An application is sent to the prescriber for completion. Upon receipt of a completed application we will send the prescriber notification regarding the patient's eligibility. If approved, medication will only be shipped to the prescriber's office. |
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| AGOURON
PHARMACEUTICALS, INC . back to top ^ Product Covered: VIRACEPT, RESCRIPTOR Telephone #: (888) 777-6637 Eligibility: Eligibility is determined on a case-by-case basis and takes into consideration an individual's circumstances. Potential applicant or representative may contact the VAP at 1-888-777-6637 between 9am and 6pm EST. Applications are mailed to the physician's office. Other Program Information: Once eligibility is determined, a monthly supply is sent to the physicians office. Enrollees must re-enroll every four months. |
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| ALZA
PHARMACEUTICALS back to top ^ Product Covered: Bicitra, Concerta, Ditropan, Elmiron, Mycelex, Neu-Phos, Neutra-Phos-K, PolyCitra,Indigent Patient Assistance Program PolyCitra-K, Progestasert, Testoderm, Urispas 1250 Bayhill Drive, Suite 300 Counties: All Arkansas Counties San Bruno CA 94066 Toll Free #: (800) 577-3788 Eligibility: Eligibility is determined by ALZA Pharmaceuticals and is based on patient's insurance status and income level. Patients must be ineligible for any other third-party reimbursement or support program to apply for the Indigent Patient Assistance Program. Other Program Information:The physician must request an Indigent Patient Assistance application from ALZA Pharmaceuticals. |
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| AMGEN
INC.
SAFETY NET Program for EPOGEN back to top ^ P.O. Box 13185 LaJolla CA 92039 Toll Free #: (800) 272-9376 Counties: All Arkansas Counties Eligibility:For patients on dialysis only. Amgen's SAFETY NET Program is designed to assist those patients who are medically indigent (patients may be uninsured or underinsured). Eligibility is based on patient's insurance status and income level. To enroll a patient, providers should contact the Amgen SAFETY NET Program by calling (800) 272-9376. Other Program Information:Providers apply on behalf of the patient. Any dialysis center, physician, hospital or home dialysis supplier may sponsor a patient by applying to the program on his or her behalf. The program is based on a 12-month patient year rather than on a calendar year. Phone-in or written applications are acceptable for program enrollment. |
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| AMGEN
INC. back to top ^ Product Covered: NEUPOGEN SAFETY NET Program for NEUPOGEN P.O. Box 13185 La Jolla CA 92039 #: (888) 508-8088 Counties: All Arkansas Counties Eligibility: Amgen's SAFETY NET Program is designed to assist those patients who are medically indigent (patients may be uninsured or underinsured). Eligibility is based on patient's insurance status and income level. To enroll a patient, providers should contact the Amgen SAFETY NET Program by calling (800) 272-9376. Other Program Information:Providers apply on behalf of the patient. Any administering physician, hospital, home health company, or community pharmacy may sponsor a patient by applying to the program on his or her behalf. The program is based on a 12-month patient year rather than a calendar year. Phone-in or written applications are acceptable for program enrollment. |
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| ASTRAZENECA back to top ^ Product Covered: ATACAND, EMLA, LEXXEL, PLENDIL, PRILOSEC, ONOCARD, Patient LP Assistance Program TOPROL-XL P.O. Box 15197 Wilmington, DE 19850-5197 Toll Free #: (800) 355-6044 Counties: All Arkansas Counties Eligibility: The AstraZeneca Patient Assistance Program is available to qualified patients with a demonstrated medical and financial need, who have exhausted third-party insurance and/or aid from Medicaid and social agencies, and who do not have other means to pay for their medication. Other Program Information: The physician's office must apply on behalf of a patient. An application is mailed to the physician, or other health care professional with prescribing authority, for his/her signature. Upon receipt and approval of a completed application, a three-month supply of medication will be shipped to the physician's office on the patient's behalf in approximately two weeks. |
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| ASTRAZENECA
FOUNDATION back to top ^ Product Covered: ACCOLATE, ARIMIDEX, NOLVADEX, SEROQUEL, SULAR, AstraZeneca Foundation TENORETIC, TENORMIN, ZESTORETIC, ZESTRIL, ZOLADEX, ZOMIG P.O. Box 15197 Wilmington DE 19850-5197 Toll Free #: (800) 424-3727 Counties: All Arkansas Counties Eligibility:Patient applications are evaluated on a case-by-case basis by the AstraZeneca Foundation. Eligibility is based on income level/assets and absence of outpatient private insurance, third-party coverage, or participation in a public program. Income eligibility is based upon multiples of the U.S. poverty level adjusted for household size. Other Program Information:Re-application is required every 12 months. A reapplication is automatically sent to enrolled patients. Patient/family members/physician can obtain application forms from the AstraZeneca Foundation by calling 1-800-424-3727. Physicians also can obtain a packer of applications from their AstraZeneca sales representative. Enrollment in the program requires a valid Social Security number. In addition, the dosage of the medication must conform to FDA approved/labeled indications and dosage regimens. |
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| AVENTIS PHARMACEUTICALS back to top ^ Product Covered: Allegra, AllegraD, Amaryl, Arava, Azmacort, Inhalation Aerosol, Patient Assistance Program Bentyl, Cantil, Carafate Tablets & Suspension, Claforan, Combipatch, DDAVP Injection, Intranasal & Tablets, Hiprex, P.O. Box 759 Somerville NJ 08876 Toll Free #: (800) 221-4025 Counties: All Arkansas Counties Eligibility: This program is designed to provide prescription medication, free of charge, to patients who qualify. Aventi will provide product to legal U.S. residents who do not have or qualify for any government or private prescription drug coverage. Additionally, the patient's total annual household income must fall below the Aventis Poverty Level. Other Program Information:Application forms can be obtained through Aventis and completed by both the physician and patient. A brand name prescription must be attached to every application. Up to a three-month supply of requested product is shipped to the physician's office to be dispensed to approved patients. A new application and prescription is required for reorder. Proof of income is required for initial enrollment and annually thereafter. |
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| AVENTIS PACT PROGRAM back to top ^ Product Covered: Anzemet, Taxotere 5870 Trinity Parkway, Suite 600, P.O. Box 230517 Centreville VA 20120 Toll Free #: (800) 996-6626 Counties: All Arkansas Counties |
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AVENTIS PASTEUR back to top ^
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| BAYER
CORPORATION PHARMACEUTICAL back to top ^ Product Covered: Most Bayer pharmacy prescription medications used as Bayer Indigent Program recommended P.O. Box 29029 Phoenix, AZ 85038-9209 Toll Free #: (800) 468-0894 ext 2765 Counties: All Arkansas Counties Eligibility: Patient must be a U.S. resident. Physician must certify patient is not eligible for, or covered by, government-funded reimbursement or insurance program for medication; patient is not covered by private insurance; and patient's household income is below federal poverty-level guidelines. Physician must indicate condition for which drug is to be prescribed and certify that drug will be used for indicated use only. Physician must agree to follow patient through therapy. All applications are subject to a case-by-case valuation by Bayer Corporation. Other Program Information:Patient/Physician can qualify over the phone by calling (800) 998-9180. If all information needed is obtained over the phone, approval or denial is given immediately. If patient is approved, an application is generated and sent to the physician's office for signatures. |
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| BIOGEN
INC. back to top ^ Product Covered: AVONEX (Interferon beta-la) Toll Free #: (800) 456-2255 Eligibility: Eligibility is based on patient's insurance status and income level. |
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| BOEHRINGER
INGELHEIM PHARMACEUTICALS back to top ^ Product Covered: AGGRENOX, ATROVENT, CAFCIT, CATAPRES-TTS, c/o ESI/SDS COMBIVENT, FLOMAX, MICARDIS, MOBIC & VIRAMUNE P.O. Box 66555 St. Louis MO 63166-6773 Toll Free #: (800) 556-8317 Counties: All Arkansas Counties Eligibility: Eligibility to be determined solely by BIPI. Patient must be a U.S. citizen ineligible for prescription assistance through Medicaid or private insurance. Patient must meet established financial criteria. Other Program Information:All requests are reviewed and approved on a case-by-case basis. Application form, prescription, and patient's income documentation are required. Maximum of three months supply may be provided per request. Compete financial re-application is required annually. Renewal requests within the same year require only the application form and a prescription. Program is subject to change without notice. Current program specifies can be obtained by calling the toll-free number above. |
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| BRISTOL-TYERS SQUIBB back to top ^ Product Covered: Many Bristol-Myers Squibb pharmaceutical products Patient Assistance Foundation, Inc. P.O. Box 4500 Princeton NJ 08543-4500 Toll Free #: (800) 332-2056 Counties: All Arkansas Counties Eligibility: This program is designed to provide temporary assistance to patients with a financial hardship who are not eligible for prescription drug coverage through Medicaid or any other public or private health program. Patients who meet the program's eligibility criteria are provided BMS products free of charge. Other Program Information:Physicians and other health care professionals who are interested in enrolling a patient should call the toll-free number above to request an application |
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| CENTOCOR
INC. back to top ^ Product Covered: REMICADE Patient Assistance Program 3060 Ogden Avenue, 3rd Floor Lisle IL 6032 Toll Free #: (800) 964-8345 Counties: All Arkansas Counties Eligibility:The REMICADE Patient Assistance Program is a service to provide product to low-income patients legally residing in the United States when patients meet certain financial need qualifications. When patients qualify, they may be provided with up to six months of product at a time. Other Program Information:Health care providers, patients, patients' guardians, and social workers may submit applications for product. All applications will require the signature of the patient or guardian as well as the health care provider. The program only provides product for eligible patients. If the patient meets the eligibility criteria, product is shipped directly to the provider's office or to the site of care. |
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| CENTOCOR
SOLUTIONS back to top ^ Product Covered: RETAVASE (reteplase, recombinant) Program for RETAVASE 1800 Robert Fulton Drive, Reston VA 20191 Toll Free #: (800) 331-5773 Counties: All Arkansas Counties Eligibility: Centocor Solutions Program ill replace RETAVASE used to treat patients who meet specific medical and financial criteria and lack third-party insurance. Other Program Information:Upon request, an application with a cover letter will be sent to the provider of service to be completed and returned with required documentation. |
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| CIBA
PHARMACEUTICALS back to top ^ Product Covered: See NOVARTIS Pharmaceuticals |
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| DuPONT
PHARMACEUTICALS back to top ^ Product Covered: Most marketed non-controlled prescription products Chestnut Run Plaza, Hickory Run Bldg. 974 Centre Rd. Wilmington, DE 19805 Toll Free #: (800) 474-2762 Counties: All Arkansas Counties Eligibility: Eligibility is based on the patient's insurance status and income level/assets. Patients should have exhausted all third-party insurance, Medicaid, Medicare, and all other available programs. The patient must be a resident of the United States. Other Program Information:The physician should request an application by calling 1-800-474-2762, prompt 5. The physician must complete and sign the physician-designated area of the application and include a signed, completed prescription. The patient must complete and sign the patient-designated area of the application and include a copy of their most current 1040 tax form. The application should be mailed to the address above. It takes approximately two weeks from receipt of an approved application for delivery of medication to the physician. |
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| EISAI
INC. back to top ^ Product Covered: Aricept (donepezil HCI) 5mg & 10mg tablets Toll Free #: (800) 226-2072 Eligibility: Eisai Inc., and Pfizer Inc., have developed the Aricept Patient Assistance Program for those U.S. residents without prescription drug coverage through either public or private insurance. Aricept will be provided free of charge to patients who meet the following criteria: Patient has no insurance or other third-party payer prescription drug coverage, including Medicaid coverage or Medicare managed care coverage. Patient's annual income must fall within a predetermined range. Patient must be diagnosed by a physician as having mild to moderate dementia of the Alzheimer's type. Other Program Information: Patient must requalify after 90-day initial supply. |
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| EISAI
INC/JANSSEN PHARMACEUTICA, INC. back to top ^ Product Covered: Aciphex (rabeprazole sodium) 20 mg tablets Aciphex Patient Assistance Program Toll Free #:(800) 523-5870 Eligibility: Eisai Inc., and Janssen Pharmaceutica, Inc., have developed the Aciphex Patient Assistance Program for those U.S. residents without prescription drug coverage through either public or private insurance. Aciphex will be provided free of charge to patients who meet the following criteria: Patient has no insurance or other third-party payer prescription drug coverage, including Medicaid coverage or Medicare managed care coverage. Patient's annual income must fall within a predetermined range. Program specialists determine eligibility for each patient. The program requests that physicians not charge patients beyond insurance coverage for professional services. Patient must be diagnosed by a physician as having a medical need for Aciphex. |
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| ELAN
PHARMACEUTICALS, INC. back to top ^ Product Covered: Permax, Janaflex, Diastat, Mysoline, Zonegran Prescription Assist. Program-c/o Athena Rx Home Pharmacy 800 Gateway Boulevard South San CA 94080 Toll Free #: (800)528-4362 Counties: All Arkansas Counties Eligibility: The patient must be a resident of the United States, have a net worth less than $30,000 and no third-party prescription drug coverage. Other Program Information:The prescribing physician and patient must provide the following to Athena Rx Home Pharmacy: a letter of denial from the state Medicaid program; the patient's most recent income tax return, three consecutive bank statements of financial statements from the same account; a letter on the physician's letterhead requesting the medication and assurance on financial need; and a prescription for a one-year supply. Once the request is approved, the product will be shipped quarterly to the patient via UPS delivery. New requests must be filed for additional product. |
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| ELI
LILLY AND COMPANY back to top ^ Product Covered: Most Lilly prescription products and insulin Lilly Cares Program Administrator P.O. Box 23099 Counties: All Arkansas Counties Centreville VA 20120 Toll Free #: (800) 545-6962 Eligibility: Patients must be U.S. residents. Eligibility is determined on a case-by-case basis in consultation with each prescribing physician. Eligibility is based on the patient's inability to pay and lack of third-party drug payment assistance, including insurance, Medicaid, government-subsidized clinics, and other government, community, or private programs. Inpatients and those who can obtain drug reimbursement from any source are not eligible. Requests for replacement drugs cannot be honored. Medications are provided directly to the physician for dispensing to the patient. Quantity of supply is dependent upon type of product being prescribed. All Lilly medications must be used as recommended in product labeling. Other Program Information:Forms to qualify a patient for the program will be provided to the physician. On this form, the physician is requested to provide prescription information, including signature and DEA number, and to confirm the patient's ineligibility for other forms of outpatient drug coverage. Additionally, the patient is requested to provide pertinent information and state financial need. Subsequent request for same patient requires another prescription and restatement of medical and financial need. Program guidelines may be subject to change. |
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| FUJISAWA
HEALTHCARE, INC. back to top ^ Product Covered: Prograf capsules (tacrolimus, FK506) c/o Covance Health Economics & Outcomes Services P.O. Box 7710 Washington DC 20044-7710 Toll Free #: (800) 477-6472 Counties: All Arkansas Counties Eligibility: Fujsawa Healthcare, Inc. developed the Prograf Patient Assistance Program to help improve access to oral Prograf for patients who have no health insurance for Prograf and limited financial resources. To be eligible for the program, patients must meet income and insurance criteria set by Fujisawa Healthcare. Please call the Prograf Reimbursement Hotline (800-4-PROGRAF) for an application or for information about eligibility. If you describe a patient's insurance and financial situation, Hotline staff can determine whether the patient is likely to qualify for the Program Patient Assistance Program. Other Program Information:To enroll a patient, physicians must first register with the program. Registered physicians may enroll patients by submitting a patient enrollment form and a prescription. If approved, the patient will receive two 90-day shipments of Prograf from a mail-order pharmacy affiliated with the program. The pharmacy will bill the patient $20 per shipment for expenses associated with dispensing the shipping the product. If continued assistance is required after six months, the physician must reapply for the patient. |
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| GEMZAR
back to top ^ Product Covered: Gemzar Gemzar Patient Assistance Program Toll Free #: (800) Eligibility:Applications for the program are available by calling the toll-free Gemzar Hotline. Applicants determined to be eligible based on program income criteria will be approved on the basis of these additional criteria; no medical insurance, and ineligible for any programs with a drug benefit provision, including Medicaid, third-party insurance, Medicare, and all other programs have denied coverage for Gemzar in writing, and all appeals have been exhausted |
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| GENENTECH,
INC. back to top ^ Product Covered: Pulmozyme (dornase alfa) Genentech Endowment for Cystic Fibrosis 4828 Parkway Plaza Blvd., Charlotte NC 28217-1969 Toll Free #: (800) 297-5557 Counties: All Arkansas Counties Eligibility: The Endowment offers three programs designed to meet the special needs of the cystic fibrosis (CF) population. If you are uninsured, the Endowment offers an Uninsured Patient Program. You may also be eligible for this program if you have insurance but the policy has certain coverage limitations, such as no drug benefit. If you have insurance, you may qualify for assistance through the Co-payment Assistance Program. This program assists qualifying patients with Pulmozyme out-of-pocket co-payment requirements based upon a sliding scale adjusted for income, family size, and other pre-established criteria. Both uninsured and underinsured patients may benefit from the premium Assistance Program. This program assists qualifying patients with insurance premium costs. Assistance levels are based upon a sliding scale. Other Program Information: Patients may be enrolled in only one program at a time. In addition to the programs described above, the Endowment assists qualifying patients with the purchase of nebulizers and compressors for Pulmozyme and administration. |
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| GENENTECH, INC. back to top ^ Product Covered: Activase (Alteplase), Herceptin (Trastuzumab), Nutropin, Genentech Assistance Program Nutropin AQ, Protropin, Rituxan & TNKase P.O. Box 2586, South San CA 94083-2586 Toll Free #: (800) 879-4747 Counties: All Arkansas Counties Eligibility: For consideration of eligibility for the Genentech Assistance Program, the patient must not be eligible for public or private insurance reimbursement and must meet income restrictions. Other Program Information:For reimbursement assistance for Nutropin, Nutropin AQ, or Protropin, the physician must contact the Single Point of Contact (SPCO) Reimbursement Department at (800) 545-0488. For reimbursement assistance for Activase or TNKase, an application must be completed by the treating hospital. For furtherinformation and assistance the physician may contact the Genetch Reimbursement Hotline at (800) 530-3083. For reimbursement assistance for Herceptin or Rituxan, an application must be completed and signed by the treating physician. |
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| GENETICS INSTITUTE, INC. back to top ^ Product Covered: Benefix Coagulation Factor IX (recombinant) The BENEFIX Reimbursement & Information Program 1101 King Street, Suite 600, Alexandria VA 22314 Telephone #: (888) 999-2349 Counties: All Arkansas Counties Eligibility: The program is designed to provide temporary assistance to patients who meet the predetermined eligibility criteria. Eligible patients must be without prescription drug coverage from a third-party payer. Patients who meet the eligibility criteria are eligible for a period of 90 days, at which time they must requalify for the program. Other Program Information:Application forms are sent to physicians who are treating specific patients who may qualify for the program. Application forms must be signed by the patient and physician prior to returning to the program. |
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| GENZYME CORPORATION back
to top ^ Product Covered: Ceredase (alglucerase injection) Cerezyme (imiglucerase for) c/o Wytske Kingma, M.D.-Medical Affairs injection) One Kendall Square Cambridge MA 01239-1562 Toll Free #: (800) 745-4447, ext 17808 Counties: All Arkansas Counties Eligibility: Based on financial and medical need. Must be uninsured and lack the financial means to purchase the drug. In order to maintain eligibility, patients and their families are expected to continue exploring alternative funding options with the Genzyme Case Management specialist. These options include private insurance, government programs and/or charitable sources. Other Program Information:The CAP Program is considered a temporary funding program. |
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GILEAD SCIENCES, INC. back
to top ^ |
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| GLAXOSMITHKLINE back
to top ^ Product Covered: All marketed Glaxo Wellcome prescription products Glaxo Wellcome Inc. Patient Assistance Program P.O. Box 52185 Phoenix AZ 85072-2185 Toll Free #: (800) 722-9294 Counties: All Arkansas Counties Eligibility: The Glaxo Wellcome Patient Assistance Program has been established to provide short-term assistance to eligible patients until alternative funding can be found. All Glaxo Wellcome medications used in an outpatient setting are available. The Glaxo Wellcome Patient Assistance Program is a philanthropic activity of Glaxo Wellcome. The Program is intended to serve patients who do not have drug benefits through private insurance or government-funded programs. The Patient Assistance Program is not intended to replace government programs. Other Program Information: The Glaxo Wellcome Patient Assistance Program not only provides medications but also provides reimbursement services to help patients locate other payment sources that may provide more comprehensive health care coverage. Health care advocates should fill out the application form and call 1-800-722-9294 to enroll patients. Completed applications are reviewed against the company's established criteria on a case-by-case basis. Income eligibility is based upon multiples of the federal poverty level adjusted for household size. The only fee that patients are required to pay to participate in the program is a nominal pharmacy co-payment. Program benefits for outpatient products are provided through pharmacies. Injectable products are provided to the health care provider via direct product shipment. |
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| GLAXOSMITHKLINE back
to top ^ Product Covered: Amoxil, Augmentin, Avandia, Bactroban, Compazine, Coreg, SmithKline Beecham Foundation Access to Care Dyazide, Famvir, Paxil, Relafin, Requip & Tagamet c/o Express Scripts/SDS P.O. Maryland MO 63043-8564 Toll Free #: (800) 546-0420 Counties: All Arkansas Counties Eligibility:The patient has a medical condition for which the medication is needed. The patient has represented that his/her annual household income is under $25,000. The cost of the patient's prescription is not fully covered by medical insurance, government aid (e.g. Medicare) or private programs, and in the opinion of the treating physician, the cost of this therapy may impose significant hardship on the patient or result in noncompliance with treatment. Other Program Information: Application forms can be obtained by calling 1-800-546-0420. The patient and the physician fill out the application and should be sure to include all information. Incomplete forms will be returned. Both patient and physician must sign the form. The physician indicates the strength and dosage of the requested product on the prescription. A separate form and prescription must be sent for each individual. All requests must be submitted on an original SB Foundation Access to Care form. Photocopies of the application will not be accepted under any circumstances. Reapplications are required. The product will be sent to the patient's home and will require a signature upon delivery. Third-party requests will not be honored. |
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| HOECHST MARION ROUSSEL, INC. back
to top ^ Product Covered: See Aventis Pharmaceutical See Aventis Pharmaceutical Other Program Information: See Aventis Pharmaceutical |
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| IMMUNEX
COROPORATION back
to top ^ Product Covered: LEUKINE, NOVANTRONE, AMICAR, THIOPLEX Immunex Patient Assistance Program Toll Free #: (800) 321-4669 Eligibility:Eligibility is based on criteria that include the patient's insurance status and income level. Patients must be ineligible for any other third-party reimbursement or support program to apply for the Immunex Patient Assistance Program. Eligibility criteria are subject to change without notice. Other Program Information:The physician applies on behalf of the patient. All requests are reviewed and approved on a case-by-case basis. Application form, prescription, and patient's income documentation are required. Once eligibility has been verified, up to a three-month supply of the prescribed medication(s) is sent directly to the prescriber's office for distribution to the patient. Program is subject to change without notice. Current program specifies can be obtained by calling 1-800-321-4669. |
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| JANSSEN
PHARMACEUTICA back
to top ^ Product Covered: Aciphex Aciphex Patient Assistance Program (Please see Eisai Inc) Counties: All Arkansas Counties Eligibility: See Eisai Inc Other Program Information: See Eisai Inc |
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| JANSSEN
PHARMACEUTICA back
to top ^ Product Covered: Jansen’s Medical Prescription Products Janssen Cares P.O. Box 222098 Charlotte NC 28222-2098 Toll Free #: (800) 652-6227 Counties: All Arkansas Counties Eligibility: Program will ensure that all RISPERDAL (risperidone) is made available free of charge to any persons who lack financial resources and third-party insurance necessary to obtain treatment. Reimbursement specialist determines eligibility for each patient. Janssen requests that physicians not charge patients beyond insurance coverage for professional services. The Risperdal Reimbursement Support Program is designed to answer physicians' and patients' questions and solve problems related to Risperdal reimbursement as efficiently and quickly as possible. |
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JANSSEN
PHARMACEUTICA back
to top ^ |
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| KNOLL
PHARMACEUTICAL COMPANY back
to top ^ Product Covered: Mavik, Rythmol, Synthroid, Tarka Knoll Indigent Patient Program-Attn: Telemarketing 3000 Continental Drive, North Mount Olive NJ 07828-1234 Toll Free #: (800) 240-3820 Counties: All Arkansas Counties Eligibility: Physicians must send a completed application form and prescription to Knoll Pharmaceutical. Applications can be obtained through the website www.rxhope.com or by calling (800) 240-3820. Applications can be submitted through the mail, via fax or through the RxHope website. Applications can be tracked through the RxHope website. Other Program Information: Decisions are made on a case-by-case basis. Prescription is required for every request. Maximum of three-month supply on any one request. |
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| LEDERLE
LABORATORIES back
to top ^ Product Covered: See Wyeth-Ayerst Laboratories Eligibility: See Wyeth-Ayerst Laboratories Other Program Information: See Wyeth-Ayerst Laboratories |
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| MERCK & CO., INC. back
to top ^ Product Covered: Aggrastat (tirofiban HCI) The Merck Patient Assistance Program for Aggrastat Toll Free #: (877) 810-0595 Eligibility: Financially disadvantaged patients may be eligible for assistance through the Merck Patient Assistance Program for Aggrastat. This program is designed to help cover the cost of Aggrastat for eligible patients who meet the following criteria; must demonstrate financial need, must not have coverage through an insurance provider, and must not be eligible for an third-party insurance or government-sponsored programs, including Medicare and Medicaid. Alternative sources of coverage must be explored before applying to the Merck Patient Assistance Program for Aggrastat. Reimbursement is not guaranteed to all applicants. Other Program Information: Hospital administrators can call the Merck Patient Assistance Program for Aggrastat at (877) 810-0595. Patient assistance experts will assist with the application process to determine eligibility. This program also offers reimbursement counseling for patients and providers to assist with any payer questions.Health car professionals who participate in this program are under no obligation to prescribe Aggrastat or any other product manufactured by Merck & Co., |
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| MERCK & CO., INC. back
to top ^ Product Covered: Most Merek products The Merck Patient Assistance Program Toll Free #: (800) 994-2111 Eligibility: The Merck Patient Assistance Program is designed to provide temporary assistance to patients who have no access to any insurance coverage for prescription medications and are truly unable to afford prescription medications. The patient must have exhausted all options for prescription benefits and coverage including private insurance, HMOs, Medicaid, Medicare, state pharmacy assistance programs, Veteran's Assistance, and any other social service agency support. Patients must also reside in the United States and have a U.S. treating physician. Completed applications are reviewed on a case-by-case basis. Other Program Information:Each application must be completely filled out and signed by both the prescriber and the patient and be mailed with an original, signed, dated prescription with the prescriber's name, address, professional designation, and a DEA or state license number. Completed applications are reviewed for eligibility on case-by-case basis. Once eligibility has been verified, up to a three-month supply of the prescribed medication(s) is sent directly to the prescriber's office for distribution to the patient. Medications are labeled for the patient. |
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| NEA
CLINIC back
to top ^ Product Covered: Prescription Coverage for Long-term Medication 3100 Apache Drive, Suite B1Jonesboro AR 72401 Telephone #: (870) 910-6038 Counties: All Arkansas Counties Eligibility: The NEA is a Charitable Foundation. The NEA Clinic assists low-income persons and families with no prescription coverage to receive long-term medications for free. The Foundation acts as a liaison between the person needing the care and the drug company. The person's doctor must be willing to sign the application for medication. |
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| NEUMEGA
back
to top ^ Product Covered: Neumega (oprelvekin) Neumega Access Program Counties: All Arkansas Counties Eligibility:For uninsured and underinsured patients who have limited financial resources. Other Program Information: Reimbursement specialists provide assistance to physicians, nurses, office managers, pharmacists and patients with insurance reimbursement, such as information on billing and coding. Service staff will also provide individualized help with claims filing and preauthorization requests and provide support in challenging claim denials. |
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NOVARTIS
PHARMACEUTICALS back
to top ^ |
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| ONCOLOGY
ACCESS TO CARE PROGRAM back to top ^ Product Covered: Hycamtin (topotecan HCI) Counties: All Arkansas Counties |
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ORGANON
INC. back to top ^ |
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| ORGANON
INC. back to top ^ Product Covered: Follistim (follitropin beta for injection), Follistim Antagon Kit Gold StarFertility Assistance Program Local Organon sales representative Counties: All Arkansas Counties Eligibility: Patients must be U.S. residents. Eligibility is determined on case-by-case basis and is based on a patient's inability to pay and who are not eligible to receive these drugs through any other third-party drug reimbursement program, i.e., Medicaid, local or federal agency programs, Blue cross/Blue Shield, private insurance programs and private foundations. Inpatients and those who can obtain drug reimbursement from other sources are not eligible. Other Program Information: Forms to qualify a patient for the program will be provided to the physician. On this form, the physician is requested to provide prescription information, including their signature and DEA number and to confirm the patient's ineligibility for other forms of outpatient drug coverage. The patient is requested to provide the pertinent information and state financial need. |
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| ORTHO
BIOTECH INC. back to top ^ Product Covered: PROCRIT for non-dialysis use, LEUSTATIN injection Procritline 1250 Bayhill Drive, Suite 300, San Bruno CA 94066 Toll Free #: (800) 553-3851 Counties: All Arkansas Counties Eligibility: Program will ensure that PROCRIT and/or LEUSTATIN is made available to any persons who meet specific medical criteria and lack financial resources and third-party coverage necessary to obtain treatment. A reimbursement specialist determines eligibility. Other Program Information: Patient eligibility application forms are available by accessing the 800 number (800-553-3851). This call can help determine if a patient is eligible to enroll in the program or is eligible for an alternative program if other sources of funding are identified. |
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ORTHO
DERMATOLOGICAL back to top ^ |
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| ORTHO-McNEIL
PHARMACEUTICAL, INC. back to top ^ Product Covered: Prescription products prescribed according to approved Ortho-McNeil Patient Assistance Program labeled indications & dosage regimens P.O. Box 938 Somerville NJ 08876 Toll Free #: (800) 797-7737 Counties: All Arkansas Counties Eligibility: Patients should not have insurance coverage for prescription medication. Patients should not be eligible for other sources of drug coverage; they need to have applied to public sector programs and been denied. Patients' income fall below poverty level and retail purchase would cause hardship. Other Program Information: Health care practitioner should request an application form. The completed form must be accompanied by a signed and dated prescription. Medication will be sent to the health care practitioner for dispensing to the patient. |
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| OTSUKA
AMERICA PHARMACEUTICAL, INC. back to top ^ Product Covered: Pletal (citstazol) Tablets RxMAP P.O. Box 29043 Phoenix AZ 85038-9988 Toll Free #: (800) 242-7014 Counties: All Arkansas Counties Eligibility: Based on federal poverty level and no prescription drug coverage. Other Program Information:All inquiries should go to RxMAP at (800) 242-7014. |
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| PARK-DAVIS
back to top ^ Product Covered: Accupril, Accuretic, Dilantin, Estrostep, FemHRT, Lipitor, The Parke-Davis Patient Assistance Program Loestrin, Neurontin & Zarontin P. O. Box 1058 Somerville NJ 08876 Toll Free #: (800) 752-1247 Counties: All Arkansas Counties Eligibility: Patients must not be eligible for other sources of drug coverage and must be deemed financially eligible based on company guidelines and physician certification. Other Program Information: Physicians should request an application form from their Parke-Davis Sales representative. The completed form, accompanied by a signed and dated prescription, should be mailed to the address above. Up to a three-month supply will be delivered to the physician for dispensing to the patient. PARKE-DAVIS Product Covered: Please see Pfizer PFIZER back to top ^ Counties: All Arkansas Counties Eligibility:Any patient that a physician is treating as indigent is eligible. Patients must have incomes below $12.000 (single) of $15,000 (family). Patients must not be receiving or be eligible for third-party or Medicaid reimbursements for medications. No co-payment or cost-sharing is required by the patient. Other Program Information:Specific forms are not required. The physician must write a letter on his or her letterhead to Pfizer stating that the patient meets income criteria and is uninsured for pharmaceuticals and enclose a prescription for the desired product. The letter must be signed by the prescribing physician. Products are shipped to the physician for redistribution to the patient. Products are supplied to the physician in stock packages, usually 100 tablets or capsules. It may take up to four weeks to receive the product. Refills are obtained through physician resubmission of request. Pfizer reserves the right to limit enrollment. (more below) |
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| PFIZER INC. back to top ^ Product Covered: Certain Pfizer single-source products Sharing the Care 235 E. 42nd Street New York NY 10017-5755 Toll Free #: (800) 984-1500 Counties: All Arkansas Counties Eligibility: The program, a joint effort of Pfizer, the National Governors' Association, and the National Association of Community Health Centers, works solely through community, migrant, and homeless health centers that are funded under section 330 (e), 330 (g), or 330 (h) of the Public Health Service Act and that have an in-house pharmacy. The program includes the participation of more than 350 health centers throughout the United States. To be eligible to participate in Sharing the Care, the patient must be registered at a participating health center, must not be covered by any private insurance or public assistance covering pharmaceuticals, must not be Medicaid-enrolled, and must have a family income that is equal to or below the federal poverty level. Pfizer reserves the right to limit enrollment of patients and health centers. Other Program Information: Product is dispensed to patient at health center pharmacy. |
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| PFIZER
INC. back to top ^ Product Covered: Most Pfizer prescription products are covered Arkansas Health Care Access Foundation P. O. Box 56248 Little Rock, AR 72215 Toll Free #: (800) 950-8233 Counties: All Arkansas Counties Eligibility:Must be an Arkansas resident to qualify. Eligible individuals are certified by the Arkansas Local County Department of Human Services as being Arkansas residents below the federal poverty guidelines, who do not have health insurance benefits and do not qualify for any government entitlement programs. No co-payment or cost-sharing is required from the patient. Physician must waive his or her fee for the initial visit. This program does not apply to individuals during hospital inpatient stays. Other Program Information:Physicians should contact the Arkansas Health Care Access Foundation for further information. |
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| PFIZER
INC. Toll Free #: (800) 869-9979 back to top ^ Product Covered: Diflucan and Zithromax for MAC prophylaxis Diflucan and Zithromax Patient Assistance Program Counties: All Arkansas Counties Eligibility: Patient must not have insurance or other third-party coverage, including Medicaid, and must not be eligible for a statels AIDS drug assistance program. Patient must have an income of less than $25,000 a year without dependents, or less than $40,000 a year with dependents. Other Program Information: Physicians should call the Diflucan and Zithromax Patient Assistance Program and explain the patient's situation to the Patient Assistance Specialist. The specialist will then send a short qualifying form that requests insurance status, income information, and the amount of Diflucan or Zithromax the patient will require. The form must be completed, signed, a prescription attached, and returned to the Patient Assistance Program in the envelope provided. The program staff will determine whether the patient is eligible for free Diflucan or Zithromax on the same day the form is received. A letter will be sent notifying the physician of the patient's eligibility or ineligibility. |
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| PFIZER
INC. back to top ^ Product Covered: Please see Eisai Inc. Aricept Patient Assistant Program Counties: All Arkansas Counties Eligibility: Eisai Inc., and Pfizer Inc., have developed the Aricept Patient Assistance Program for those U.S. residents without prescription drug coverage through either public or private insurance. Aricept will be provided free of charge to patients who meet the following criteria: Patient has no insurance or other third-party payer prescription drug coverage, including Medicaid coverage or Medicare managed care coverage. Patient's annual income must fall within a predetermined range. Patient must be diagnosed by a physician as having mild to moderate dementia Other Program Information:Patient must requalify after 90-day initial supply. |
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| PFIZER
INC. back to top ^ Product Covered: Most Pfizer outpatient products with chronic indications are Pfizer Prescription Assistance covered by this program. P. O. Box 23097 Centreville VA 20120 Toll Free #: (800) 646-4455 Counties: All Arkansas Counties Eligibility: Any patient that a physician is treating as indigent is eligible. Patients must have incomes below $12.000 (single) of $15,000 (family). Patients must not be receiving or be eligible for third-party or Medicaid reimbursements for medications. No co-payment or cost-sharing is required by the patient. Other Program Information: Specific forms are not required. The physician must write a letter on his or her letterhead to Pfizer stating that the patient meets income criteria and is uninsured for pharmaceuticals and enclose a prescription for the desired product. The letter must be signed by the prescribing physician. Products are shipped to the physician for redistribution to the patient. Products are supplied to the physician in stock packages, usually 100 tablets or capsules. It may take up to four weeks to receive the product. Refills are obtained through physician resubmission of request. Pfizer reserves the right to limit enrollment of |
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| PHARMACIA
CORPORATION back to top ^ Product Covered: Numerous products RxMAP P. O. Box 29043 Phoenix AZ 85038 Toll Free #: (800) 242-7014 Counties: All Arkansas Counties Eligibility: Based on federal poverty level and no prescription drug coverage. Other Program Information: All inquiries should go to RxMAP at (800) 242-7014. |
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| PRESCRIPTION
ASSISTANCE LINE FOR SENIORS back to top ^ Product Covered: Telephone #501-569-350 Counties: All Arkansas Counties |
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| PROCTER & GAMBLE PHARMACEUTICALS, INC.
back to top ^ Product Covered: Actonel, Asacol, Dantrium, Didronel, Macrodantin, Macrobid c/o Express Scripts P. O. Box 6553 St. Louis MO 63166-6553 Toll Free #: (800) 830-9049 Counties: All Arkansas Counties Eligibility: Procter & Gamble Pharmaceuticals has always tried to ensure that all patients have full access to its products. To qualify, patients should have exhausted prescription coverage through private or public insurance. Each patient's case is handled on an individual basis. The company relies on the physician's assessment of need to determine eligibility. Application forms are provided by the company for the physician/patient to complete. An original prescription duly signed by the attending physician for one of the company's products is required. Other Program Information: The quantity of product supplied depends on diagnosis and need, but generally a three-month supply is provided for a chronic medication. Refills require anew prescription and application form from the physician. The prescription medication is sent directly to the physician, who provides it to the patient. Applications are good for one year. Afterwards, patients must be re-screened to ensure continued eligibility. |
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| RHONE-POULENC
RORER INC. back to top ^ Product Covered: See Aventis Pharmaceuticals See Aventis Pharmaceuticals Eligibility:Determined on a case-by-case basis. Limited to those individuals who have been identified as indigent, uninsured, and ineligible for Medicare and Medicaid; is not eligible for other programs offered by the state, country or city; the patient is a U.S. resident; patient's household income is below federal poverty guidelines. Physician must waive all fees associated with treating the patient and certify product will not be sold, traded, or used for any other purpose but to treat the patient applying for assistance. Other Program Information: Aventis Pasteur reserves the right to modify or discontinue the Indigent Patient Program at any time for any reason. An application form must be completed, call 1-800-VACCINE to receive an application. Rabies - The physician needs to specify the quantity of IMOGAM Rabies needs for patient (in mL) as well as the nub number of doses of IMOVAX Rabies, along with the patient's age and weight. TheraCys - Six doses are provided for one induction course of therapy. Connaught does provide, under the program, for a full course of therapy induction and maintenance - which may be as high as 11 doses (six doses for induction plus as many as five doses for maintenance) at the physician's discretion. |
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| ROCHE
LABORATORIES, INC. back to top ^ Product Covered: CellCept, CYTOVENE, CYTOVENE-IV, Roche Transplant Reimbursement Hotline Toll Free #: (800) 772-5790 |
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| ROCHE
LABORATORIES, INC. back to top ^ Product Covered: Roche product line with some exceptions Roche Medical Needs Program 340 Kingsland Street Nutley NJ 07110 Toll Free #: (800) 285-4484 Counties: All Arkansas Counties Eligibility: The Roche Medical Needs Program is designed as an interim solution for patients who lack third-party outpatient prescription drug coverage under private insurance, government-funded programs (e.g., Medicaid, Medicare, Veterans Affairs, etc.), or private/community sources and are unable to afford to purchase our products on their own. Roche offers the Medical Needs Program as a philanthropic endeavor to assure access to Roche products for needy patients at no charge until alternative funding can be found. The Roche Medical Needs Program is part of Roche's commitment to assure access to our products and is not intended to supplant or replace prescription drug coverage provided by third-party public or private payers. This program is for individual outpatients who meet the Medical Needs Program criteria and is offered through licensed practitioners. The program is not intended for clinics, Other Program Information:Roche Medical Needs Program forms obtained from the Medical Needs Department are required. Applications are provided only to licensed practitioners. Physicians' and patients' signatures, and a state license number, or a DEA number, if a controlled substance is requested, are required on the application. A new application form must be completed for patients requiring refills. All completed applications will be reviewed and approved by Roche on a case-by-case basis using the established criteria of the program. Patients and providers may be requested to participate in reimbursement case management based on the product requested. Up to a three-month supply of product will be shipped directly to the licensed practitioner within two to three |
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| ROCHE
LABORATORIES, INC. back to top ^ Product Covered: Roferon-A, Kytril, Vesanoid, Xeloda, Fluorouracil Oncoline/Hepline Reimbursement Hotline Toll Free #: (800) 443-6676 (Press 2 or 3) |
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| ROCHE
LABORATORIES, INC. back to top ^ Product Covered: FORTOVASE, INVIRASE, CYTOVENE, CYTONVENE-IV, HIVID Roche HIV Therapy Assistance Program Toll Free #: (800) 282-7780 |
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| ROXANE
LABORATORIES, INC. back to top ^ Product Covered: Oramorph SR, Roxanol, Roxicodone Boehringer Ingelheim Pharmaceuticals, Inc. P. O. Box 66555-c/o ESI/SDS St. Louis MO 63166-6773 Toll Free #: (800) 556-8317 Counties: All Arkansas Counties Eligibility: Eligibility to be determined solely by Boehringer Ingelheim Pharmaceuticals, Inc., and Roxane Laboratories. Patient must be a U.S. Citizen ineligible for prescription assistance through Medicaid or private insurance. Patient must meet established financial criteria. Other Program Information:All requests are reviewed and approved on a case-by-case basis. Application form, prescription, and patient's income documentation are required. Maximum of three months supply may be provided per request. Complete financial re-application is required annually. Renewal requests within the same year require only the application form and a prescription. Program is subject to change without notice. Current program specifics can be obtained by calling the toll-free number (800) 556-8317. |
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| SANDOZ
PHARMACEUTICAL CORPORATION back to top ^ Product Covered: See Novasrtis Pharmaceuticals See Novasrtis Pharmaceuticals Eligibility: The Patient Assistance Program provides temporary assistance to patients who are experiencing financial hardship and who have no prescription drug insurance. Patients are required to complete an application along with their physicians and return it for evaluation. Other Program Information:Patient applications are evaluated on a case-by-case basis. |
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| SANKYO
PHARMA back to top ^ Product Covered: WelChol (colesevelam HCI) Sankyo Pharma Open Care Program P. O. Box 8409 Somerville, NJ 98876 Telephone #: 866-268-7327 Counties: All Arkansas Counties Eligibility: The Sankyo Pharma Open Care Program is available to qualified patients with demonstrated medical and financial need. The program assists patients who are prescribed Sankyo products and are uncertain of their insurance coverage, in locating alternative payment sources. Free product is provided to uninsured patients who qualify and for whom no alternative source of reimbursement can be identified. Patients must reside in the United States and have a U.S. treating physician. Other Program Information:The physician's office must apply on behalf of a patient. Applications are available from Sankyo Pharma representatives or from Sankyo Pharma Open Care Program hotline - (866) 268-7327. Upon receipt and approval of a completed application, all patients will receive a supply (the amount depends on the product) of medication, which will be shipped to the physician's office on the patient's behalf. Patients who remain on therapy will complete reimbursement counseling to identify alternative sources of insurance. Patients without alternative sources of insurance will continue to receive free product. Periodic reviews of applications will be conducted to ensure continued eligibility. |
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| SANOFI-SYNTHELABO
INC. back to top ^ Product Covered: Aralen, Danocrine, Drisdol, Hytakerol, Mytelase, NegGra Needy Patient Program-c/o Product Information Dept 90 Park Avenue New York NY 10016 Toll Free #: (800) 446-6267 Counties: All Arkansas Counties Other Program Information:The physician's office should contact the Sanofi-Synthelabo Product Information Department to apply on behalf of a patient. An application is sent to the physician's office for completion and signature, in addition to a signed prescription. Upon receipt of completed application and prescription from physician, and upon approval of application, medication will be shipped directly to the physician's office from the distribution center. Each patient can receive a 3-month supply of medication, with an option of one refill for an additional three months supply for a total of six months medication for one year. The physician must contact Sanofi-Synthelabo's office for the refill. |
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| SCHERING
LABORATORIES/KEY PHARMACEUTICALS back to top ^ Product Covered: Most Schering/Key Prescription drugs Patient Assistance Program P. O. Box 52122 Phoenix AZ 85072 Toll Free #: (800) 656-9485 Counties: All Arkansas Counties Eligibility: The program is designed to assist those patients who are truly in need -indigent - who are not eligible for private or public insurance reimbursement and who cannot afford treatment. Patient eligibility is determined on a case-by-case basis based upon economic and insurance criteria. Eligibility criteria are currently being reevaluated and may be subject to change. Other Program Information: Physician and patient complete an application form. Application is reviewed on a case-by-case basis. Repeat requests require a new application form to be completed. |
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| SEARLE
Product Covered: See aslo Pharmacia. Aldactazide,
Aldactone, Calan SR, Kerlone, Covera-HS back to top ^ Eligibility: Based on federal poverty level and no prescription drug coverage. Patients in Need Foundation
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| SERONO
LABORATORIES, INC. back to top ^ Product Covered: Saizen (somatropin [rDNA origin]) Connections for Growth Toll Free #: (800) 582-7989 Counties: All Arkansas Counties |
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| SERONO
LABORATORIES, INC. back to top ^ Product Covered: Serostim for treatment of AIDS wasting SeroCare 100 Longwater Circle Toll Free #: (800) 714-2437 Norwell, MA 02061 Counties: All Arkansas Counties |
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| SIGMA-TAU PHARMACEUTICALS, INC. back to top ^ Carnitor Drug Assistance Program-c/o NORD P. O. Box 8923 Toll Free #: (800) 999-NORD New Fairfield, AR Counties: All Arkansas Counties Eligibility: All applicants must be citizens or permanent residents of the United States. Eligibility is determined by medical and financial criteria and applied to a cost-share formula. A patient applying for eligibility under the CDA Program must first demonstrate having a legal prescription for Carnitor. Second, the applicant must prove financial need above and beyond the availability of federal and state funds, private insurance or family resources. If an applicant is a minor or an adult dependent, NORD may request financial information of family members or guardians before determining the applicant's eligibility. Applications must be submitted annually to determine continued medical and financial eligibility. Acceptance into the program at any time does not guarantee ongoing eligibility, nor does it mean that applicants are entitled to or will be granted benefits at a later time. |
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| STATE
AND FEDERAL ASSOCIATES Product Covered: FOSCAVIR (foscarnet sodium) Injection back to top ^ 1101 King Street Alexandria VA 22314 Counties: All Arkansas Counties Eligibility: If the patient is not covered for outpatient prescription drugs under private insurance or a public program, the patient's income must fall below the level selected by the company. If the patient has insurance coverage for outpatient prescription drugs, he or she may be eligible for assistance with deductibles or maximum benefit limits. Eligibility is determined by the company based on income information provided by the physician. Other Program Information: Referral must be made by the physician. |
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| THE
LIPOSOME COMPANY, INC. back to top ^ Product Covered: ABELCET (amphotericin B lipid complex injection) Financial Assistance Program for ABELCET One Research Way Telephone: 800.335.5476 Princeton NJ 08540-6619 Counties: All Arkansas Counties Eligibility: Patients must be uninsured (not eligible to receive reimbursement through any other third-party drug reimbursement program, I.e., Medicaid, local or federal agency programs, Blue Cross/Blue Shield, private insurance programs and private foundations), and are unable to pay for the product out-of-pocket. Eligibility is determined by The Liposome Company based on medical and financial information provided on behalf of the patient by the hospital or physician. Other Program Information:Patients must receive ABELCET from a hospital, physician, or home health care company for a medically appropriate application. Providers may enroll a patient by calling (800) 335-5476 or by contacting a Liposome Area Sales Manager to obtain an application form. Application forms must be completed and signed by a physician to enroll a patient. |
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| THE
SUPPORT PROGRAM FOR CRIXIVAN back to top ^ Product Covered: Crixivan (indinavir sulfate) Reimbursement Support & Patient Assistance Service Counties: All Arkansas Counties Eligibility: The SUPPORT program assists patients who are prescribed Crixivan and are uncertain of their insurance coverage, in locating payment sources for Crixivan Free product is provided to those uninsured patients who qualify, and for whom no alternative source of coverage can be identified. Patients must also reside in the United States and have a U.S. treating physician. All applications are reviewed on a case-by-case basis. Product is shipped to the prescriber's office for distribution to the patient. Medicine is labeled for the patient. |
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| TAKEDA
PHARMACEUTICALS AMERICA back to top ^ Product Covered: ACTOS Patient Assistance Program Telephone #: 877-825-3327 Counties: All Arkansas Counties |
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| WYETH-AYERST
LABORATORIES back to top ^ Product Covered: The Norplant 5-year contraceptive system The Norplant Foundation Telephone #: 703-706-5933 Counties: All Arkansas Counties |
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| WYETH-AYERST
LABORATORIES back to top ^ Product Covered: ENBREL Rheumatoid Arthritis Assistance Foundation Telephone #: 800-282-7704 Counties: All Arkansas Counties |
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