Drug Information
Drug	Benzamycin Topical Gel 46.6g
Generic Equivalent	erythromycin; benzoyl peroxide
Topic	Skin
Program Contact Info / Application Submission
Program	Dermik Patient Assistance Program
Company	Dermik
Address	PO Box 65Somerville, NJ 08876
Phone	1-866-268-7326
Fax	866-910-9024
Program Details
Details	Up to a 90-day supply is sent to the doctor's office. A copy of the application with new dates, new signatures and a new prescription is needed for refills. Once a year a new application with financial documentation is needed.
Program Requirements
Information	The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number. The patient must fill out a section, sign the application and attach proof of income.
Details	Insurance card will be considered on a case by case basis Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income NOT required as proof of income
Delivery of Medication
Ship Time	72 hours once received
Delivery Options	Can NOT be delivered directly to the patient Can be delivered directly to the doctor
Application Process
App Process	With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application must be mailed back. Both the patient and doctor are notified in writing of acceptance or denial. Allow 4 weeks for processing and delivery of medication
New Applications	New applications accepted Can apply for a new application via fax Can apply for a new application via mail
Refills	Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can apply for refills Can NOT apply for refills via phone Can apply for refills via fax Can apply for refills via mail
Re-Applications	Re-Applications accepted Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals accepted Doctors can apply for Income Appeals Hardship Appeals accepted on a case by case basis Can apply via fax Can apply for an appeal via mail
Eligibility
Eligibility	The patient must not have any private nor public insurance and have an income at or below 200% of the Federal Poverty Level. The patient must also be a US resident. Patients who are enrolled in Medicare Part D, or in the 'Donut Hole' are not eligible for this program
Limitations	Patients are eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are NOT eligible if prescription is not covered Patients are NOT eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients may be eligible if they are accepting Medicare part D on a case by case basis
Appeals
Conditions	Appeals may be consider out-of-pocket expenses on a case by case basis
Other Medications
Other  Medications  available in  this program	Benzagel - Skin (Generic: benzoyl peroxide) BenzaGel Wash - Skin (Generic: ) Benzamycin Topical Gel 46.6g - Skin (Generic: erythromycin; benzoyl peroxide) Hytone Cream 56.8g Tube - corticosteroid Skin (Generic: ) Psorcon E Cream 60g Tube - Skin (Generic: diflorasone) Psorcon E Ointment 60g Tube - (Generic: )