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Program Details

REGENERON PHARMACEUTICALS, INC.
Libtayo Surround Program

Libtayo injection (cemiplimab-rwlc)
 
CONTACT INFO
Address: PO Box 220262
Charlotte, NC 28211-0262
Phone: 1-877-542-8296 Provider Phone:
Fax: 1-833-853-8362 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must meet income requirements and are uninsured, lack coverage for LIBTAYO, or have Medicare Part B with no supplemental insurance coverage.
  • Patients with Medicare Part D are not eligible.
  • Program also provides co-pay and reimbursement assistance.
  • Income at or below: Single 500 % FPL
      Couple 500 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Not Published
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Not Published
    Physician License #
    Required:
    Both DEA and State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Varies
    Shipped To: Provider
    Quantity in Shipment: Varies
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Refill form sent with each supply
    Other Information:

    Last Updated: 11/21/2023

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Form (Spanish)



     

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