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Programs for Special Medical Conditions -- Eligibility

Patients must meet the following criteria to be eligible for THESE PROGRAMS' assistance:

- The patient must be getting treatment for the disease named to which he or she is applying.

- The patient must have health insurance that covers his or her qualifying medication or product.

- The patient's medication or product must be listed on the covered medications below.

- The patient's income must fall at or below 400% or 500% of the Federal Poverty Guidelines, depending on fund-specific guidelines.

- The patient must reside and receive treatment in the United States or U.S. territories. ( U.S. citizenship is not a requirement.)

The following patient information is required to complete the application:

- Diagnosis and medication name

- Demographics: Name, address, phone number, and e-mail address.

- Income: Adjusted gross income applicable to the patient and all members of the patient's household.

- Insurance: Health insurance and pharmacy card(s).

- Physician Demographics: Prescribing physician name, phone number, and facility address.

Applicants are required to attest that the application information provided is complete and accurate. Reported financial information may be verified by an audit, as deemed necessary by the provider.

Programs for Special Medical Conditions -- Frequently Asked Questions, FAQ

1. Where should I send my enrollment application?

2. How long does the approval process take and how will I know whether I've been approved?

3. What if I am not approved and still have high copayments?

4. Once I am approved for a grant, how long is my eligibility period

5. How much assistance will I receive?

6. How do I submit a claim?

7. Who receives payment from the PAN?

8. How can I check my grant balance?

9. How do I use my PAN ID card?

10. What should I do if I lose my PAN ID card?

11. Can I obtain reimbursement for medication expenses I received before I began assistance with PAN?

12. What if I change my contact information, provider, or medications?

13. My enrollment period is ending soon. Is my assistance renewable?

1. Where should I send my enrollment application?

You may mail or fax your enrollment application:

Mail: Fax:

2. How long does the approval process take and how will I know whether I've been approved?

When your provider sends the necessary information, you will instantly receive your eligibility determination.

Note: You will receive a formal approval letter and benefit card in the mail within a week. Your provider will also receive an approval letter within the same time period.

3. What if I am not approved and still have high copayments?

To determine financial eligibility, this program applies a standard income deduction that varies based on insurance type. Individuals with income levels that still do not allow them to qualify will be provided with a referral to available third-party programs.

4. Once I am approved for a grant, how long is my eligibility period?

Assistance starts on your approval date and continues for 12 months. Your exact eligibility dates will be included in your approval letter, and can be accessed any time using the program's automated telephone system, at 1-866-316-7263.

Note: AN ADDED BONUS' During your initial eligibility period, eligible expenses incurred up to 90 days prior to your approval date may also be submitted to PAN for reimbursement.

5. How much assistance will I receive?

Grant amounts vary for each disease-specific program. Your approval letter will contain this information.

6. How do I submit a claim?

Patients, healthcare providers and pharmacies may submit requests for reimbursement to this program for medications covered by their disease fund. Charges incurred within 90 days prior to the eligibility date will be considered for payment during the first year of PAN coverage. All eligible expenses must be submitted within 120 days of the eligibility end date.

Patients

Primary insurance must be billed prior to the claim being submitted to the program for reimbursement. In addition, the primary insurance must consider the charge to be an eligible expense.

Physicians/Health Care Providers

Primary insurance must be billed prior to the claim being submitted to the program for reimbursement. In addition, the primary insurance must consider the charge to be an eligible expense.

Claims can be filed through any of the three methods below:

Submit electronically using payer ID 38225

Mail to: Directly to the program

Fax to: 1-844-726-4728

Note: A copy of the explanation of benefits from the primary payer must be attached when you submit your claim.

Pharmacies

Primary insurance must be billed prior to the claim being submitted to this program for reimbursement. In addition, the primary insurance must consider the charge to be an eligible expense.

The program grantees will present for payment his or her benefit card. If the patient does not have his or her benefit card, pharmacies may contact the program toll free at: 1-866-316-7263, Monday through Friday, 9 a.m. to 5 p.m. EST, for electronic billing assistance.

Claims can be filed through two methods listed below:

- Submit electronically using RX BIN 006012, PCN: MEDDPDM. You must use patient Billing ID and RX Group ' this can be found on the patient's ID card.

- Mail to directly to the program: PO Box 221858 Charlotte , NC 28222-1858 (CMS-1500 or UB-40 must be used with this method of submission)

Note: A copy of remittance advice/invoice from the primary payer must be attached when you submit your claim.

7. Who receives payment from the program?

Payment from this program can be made to a pharmacy or healthcare provider who supplies the treatment, as well as directly to a patient if the patient paid out-of-pocket for eligible expenses.

8. How can I check my grant balance?

You can check your grant balance by calling 1-866-316-7263 and speaking to a customer service representative. Customer service representatives are available, Monday through Friday, 9 a.m. to 5 p.m. EST.

9. How do I use my ID card?

Present your ID card at your doctor's office or at a participating pharmacy at the time services are rendered.

10. What should I do if I lose my ID card?

If you misplaced or do not have your benefit card, the pharmacy can call 1-866-316-7263, extension 72244 for electronic billing assistance, which is available Monday through Friday, 9 a.m. to 5 p.m. EST.

11. Can I obtain reimbursement for medication expenses I received before I began assistance with this program?

During your initial enrollment period, this program will consider for reimbursement medication expenses incurred up to 90 days prior to your approval date.

12. What if I change my contact information, provider, or medications?

A change in your contact information, provider or medications will not change your enrollment. If your information has changed, call us at 1-866-316-7263 to update your records.

13. My enrollment period is ending soon. Is my assistance renewable?

If you meet the program-specific eligibility criteria, you are eligible for a renewal grant at the end of the enrollment period, if funds are available. The program will automatically send you a renewal application at the end of your enrollment period if the specific disease program is accepting renewal patients.