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Click ‘Get Form’ to open the Patient Assistance Program Application in our editor.
Begin with Section 1, where the patient fills in their personal information including name, date of birth, and contact details. Ensure all fields are completed accurately.
Next, provide insurance information by checking applicable boxes and entering policy details. Attach copies of insurance cards as required.
In the financial section, input your current monthly household income and number of individuals in your household. Include necessary documentation for income verification.
Read through the Patient Authorization section carefully before signing. This grants permission for sharing health information as needed for program eligibility.
Finally, ensure that both the patient and prescriber complete their respective sections and sign where indicated before faxing the application to the provided number.

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Who is eligible for the patient assistance program?

Be a US citizen or legal resident. Have a total household income at or below 400% of the federal poverty level. Must be uninsured, or have Medicare. Note: if you have private or commercial insurance, you are not eligible for the PAP.

Who pays for patient assistance programs?

If youre struggling with prescription drug costs, PAPs can help you afford medication whether you have health insurance or not. Pharmaceutical companies, nonprofit organizations, and government agencies, provide this type of financial assistance.

Is there an income limit for AbbVie Assist?

Patients with Medicare and income below 150% FPL will not be eligible for myAbbVie Assist unless you have applied and been denied for that Program. Please include a denial letter with your PAP enrollment.

Does Ozempic offer a patient assistance program?

Who is Eligible for Lilly Cares? Before applying, check if you meet the programs requirements: Income Limits:Your annual household income must be at or below 300% of the Federal Poverty Level. Insurance Status:You should be uninsured or underinsured.

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