Back to Top

How to Apply

 

PAN offers two easy ways to apply for co-payment assistance:

1. Apply over the phone at 1-866-316-7263

Monday through Friday, 9 a.m. to 5 p.m. EST

2. Apply online through our self-service portals 24/7

Application Checklist

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 PAN.

For more information, please see our Frequently Asked Questions.

Apply Online

Apply Now

 

Or call 1-866-316-7263