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Program Details
BAYER HEALTHCARE PHARMACEUTICALS
Bayer Patient Assistance Program - Angeliq
Angeliq
(drospirenone/estradiol
)
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| CONTACT
INFO |
|
| Address: |
6 West Belt, W66
Wayne, NJ 07470-6806 |
| Phone: |
1-866-575-5002 |
Provider Phone: |
|
| Fax: |
1-866-575-6568 |
Website: |
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| ELIGIBILITY
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| Eligibility
Info: |
NOTE: Angeliq is hormone therapy with 17-B estradiol and drospirenone to treat moderate-to-severe vasomotor symptoms in menopausal women. It is not a contraceptive.
Patient cannot have prescription insurance or be enrolled in any government or private prescription plans including, but not limited to Medicare Part D, Medicaid, State-sponsored Presription Assistance Programs, military, retirement, pension program drug coverage, etc.
Pharmacy discount cards or other patient assistance programs are not considered coverage. |
| Income at or
below: |
Single |
|
% FPL |
| |
Couple |
|
% FPL |
| Other Income
Requirements: |
Income guidelines not disclosed. |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security
# requested on form: |
Yes |
| US citizenship/residency specified:
|
Yes |
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|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
Both DEA and State
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Provider
|
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| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
90 days
|
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12
months
|
| Refill Policy: |
3 refills
|
| Other Information: |
The patient or doctor should call for an application. The application is sent to the doctor's office. The completed application can be faxed or mailed back. The doctor is notified of acceptance or denial. The medication is usually shipped within 7-10 days.
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Last Updated: 12/11/2009
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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)
Instructions (English)
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