rxhelp360.org
| Drug Information | ||||||||||
| Drug | Vesanoid | |||||||||
| Class | retinoids | |||||||||
| Topic | Cancer | |||||||||
| Program Contact Info / Application Submission | ||||||||||
| Program | ONCOLINE Patient Assistance Program | |||||||||
| Company | Roche | |||||||||
| Phone | 877-757-6243 | |||||||||
| Fax | 866-496-8702 | |||||||||
| Program Requirements | ||||||||||
| Details | Insurance card NOT required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero incomeNOT required as proof of income Form 4506T (If taxes were not filed) required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer NOT 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 | ||||||||||
| Delivery Options | Can be delivered directly to the patient Can be delivered directly to the doctor | |||||||||
| Application Process | ||||||||||
| New Applications | New applications will be considered on a case by case basis Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can NOT apply for a new application via fax Can apply for a new application via mail | |||||||||
| Refills | Refills accepted Patients can NOT apply for refills Doctors can apply for refills Advocates can NOT 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 Patients may apply for Re-Applications on a case by case basis Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can NOT Re-Apply via fax Can Re-Apply via mail | |||||||||
| Appeals | Income Appeals accepted Patients can apply for Income Appeals on a case by case basis Doctors can apply for Income Appeals on a case by case basis Advocates can apply for Income Appeals Hardship Appeals accepted Patients can apply for Hardship Appeals on a case by case basis Doctors can apply for Hardship Appeals on a case by case basis Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can apply for an appeal via mail | |||||||||
| Eligibility | ||||||||||
| Limitations | Patients are eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare | |||||||||
| Appeals | ||||||||||
| Conditions | Appeals will consider out-of-pocket expenses Appeals may be consider total medical expenses on a case by case basis | |||||||||
| Other Medications | ||||||||||
| Other Medications available in this program |
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