| |
Program Details
BAYER HEALTHCARE PHARMACEUTICALS
Betaseron Patient Assistance Program
Betaseron
(interferon beta-1b
)
|
| CONTACT
INFO |
|
| Address: |
PO Box 221349
Charlotte, NC 28222-1349 |
| Phone: |
1-877-836-5724 |
Provider Phone: |
|
| Fax: |
1-877-744-5615 |
Website: |
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|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must meet program income guidelines, which are not disclosed.
Patients must have a confirmed physician diagnosis of multiple sclerosis and be a U.S. resident (with a valid Social Security Number or an alien registration number). |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security
# requested on form: |
Yes |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
Patient Consent Form
A copy of the most recent federal tax return is preferred, along with verification of any Social Security benefits received.
Copy of insurance card(s) (front and back) and insurance denial for Betaseron, if applicable.
|
Physician
License #
Required: |
DEA
Federal Tax ID Number
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
|
| Quantity in
Shipment: |
Up to a 90-day supply
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12
months
|
| Refill Policy: |
The patient must contact program to arrange refills.
|
| Other Information: |
|
|
|
Last Updated: 08/11/2010
|
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Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
Form (Spanish)
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|
