Patients applying for financial assistance for their copayments need to have access to the following information:
You will need to select the disease, for which you are seeking assistance, insurance type, and medication. If you are commercially insured, and have selected a medication, for which the manufacturer program has a co-pay card program, you will be made aware under the alternative programs box. Please check it out as manufacturer programs may be more generous than what PAN has to offer.
You will need to select the use type. If you are the patient, then click the box "I am applying for myself". If you are an advocate, then click the "I am applying for someone else" box. If you are a specialty pharmacy, you will need to undergo the training with PAN Foundation. Please contact Korab Zuka at email@example.com
or 202.347.9273 for more information.
You will need to access to the following information for the patient:
Social Security Number or Alien Number
Date of Birth
Language the patient speaks and understands
Number of people in the household
If you or anyone in your household is employed, how much income was received by wages, tips, or
salaries? (If you file a tax return, this information can be found on line 7 of the 1040 form or line 1 of the 1040 EZ form. You may also find this information on a W-2 form).
If you or anyone in your household receive income from IRA distributions, pensions, or annuities, how much
did you receive? (If you file a tax return, this information can be found on line 15a or 16a of 1040 form. You may also find this information on a 1099 form).
If you or anyone in your household receive Social Security Benefits, what was the amount of the benefits
received? (If you file a tax return, this information can be found on line 20a of 1040 form. You may also find this information on the 1099 or the Award letter provided annually by the Social Security Administration).
Do you receive any other income (child support, alimony, rental income, etc.)?
Is this income reflective of your current income?
Primary Insurance Carrier:
Policy ID Number
You will have the option to enter secondary insurance carrier
What is your co-pay or coinsurance for your "name of the disease fund" medications?
Do you receive assistance from any other co-pay or coinsurance assistance organizations?
How did you first hear about Patient Access Network?
Please review your application to make sure the information entered is correct and then submit your application online.