Drug:

 
Program Contact Info / Application Submission
Program Amylin Reimbursement Hotline
Company Amylin
Form Download PDF
Address P.O. Box 42886 Cincinnati, Ohio 45232
Phone 800-330-7647 opt 1
Fax 800-330-7718
Website http://www.amylin.com/products/reimbursement.cfm
 
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 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 required as proof of income
Most recent check/check stub copy required as proof of income
Letter from employer accepted 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 accepted as proof of income
 
Delivery of Medication
Ship Time 2-3 weeks
Delivery Options Shipped as a voucher card
 
Application Process
New Applications New applications accepted
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
Re-Applications Re-Applications accepted
Patients can apply for Re-Applications
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
Doctors can apply for Income Appeals
Advocates can apply for Income Appeals

Hardship Appeals accepted
Patients can apply for Hardship Appeals
Doctors can apply for Hardship Appeals
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 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 are NOT eligible if they are accepting Medicare part D
Patients are NOT eligible if the medication is not covered under Medicare
Patients are NOT eligible if Medicare coverage has been exhausted
 
Appeals
Conditions Appeals will consider out-of-pocket expenses
Appeals will consider total medical expenses
Appeals may be made before the patient has been denied on a case by case basis
 
Other Medications
Other
 Medications
 available in
 this program
Byetta injection 5mcg - Insulin Diabetic (Generic: exenatide)
Byetta injection 10mcg - (Generic: exenatide)
SymlinPen 60mcg - (Generic: pramlintide acetate injections)
SymlinPen 120mcg - (Generic: pramlintide acetate injections)
 
 
Program Contact Info / Application Submission
Program Amylin Reimbursement Hotline
Company AmylinSy
Address PO Box 8435, Gaithersburg, MD 20898
Phone 800-330-7647
Website /papforms/amybye1003.pdf
 
Program Details
Details Patients are sent a pharmacy card. A new application is needed every six months.
 
Program Requirements
Information Patients must fill out their section, sign the application and attach proof of income. The doctor will need to provide a prescription to the patient.
Details Insurance card 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) NOT 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 accepted as proof of income
Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income
Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income
Notarized statement from patient stating zero income accepted as proof of income
 
Delivery of Medication
Ship Time 2-3 weeks
Delivery Options
 
Application Process
App Process Patients or doctors need to call for a prescreening. Applications are sent to either the doctor or patient. Completed applications must be mailed back. Both the patient and doctor are notified of acceptance into the program. Decisions are usually made within 2 weeks.
New Applications New applications NOT accepted
Patients can NOT apply directly to the program
Doctors can NOT apply directly to the program
Advocates can NOT apply directly to the program

Can apply for a new application via phone
Can apply for a new application via fax
Can NOT apply for a new application via mail
Re-Applications Re-Applications NOT accepted
Patients can NOT apply for Re-Applications
Doctors can NOT apply for Re-Applications
Advocates can NOT apply for Re-Applications

Can Re-Apply via phone
Can Re-Apply via fax
Can NOT Re-Apply via mail
Appeals Income Appeals NOT accepted
Patients can NOT apply for Income Appeals
Doctors can NOT apply for Income Appeals
Advocates can NOT apply for Income Appeals

Hardship Appeals NOT accepted
Patients can NOT apply for Hardship Appeals
Doctors can NOT apply for Hardship Appeals
Advocates can NOT apply for Hardship Appeals

Can apply for an appeal via phone
Can apply via fax
Can NOT apply for an appeal via mail
 
Eligibility
Eligibility The patient can have no insurance coverage and meet the income guidelines, which are not disclosed. In addition, they must be taking the medication for an on-label diagnosis. Patients must be US residents. Patients who are eligible for Part D but did not enroll may still be eligible for this program. However, patients who are enrolled in Medicare Part D, but in the Donut Hole are not eligible for this program.
Limitations Patients are eligible with existing prescription coverage
Patients are eligible if prescription is not covered
Patients are eligible if prescription coverage has been exhausted
Patients are NOT eligible if they are accepting Medicare
Patients are eligible if they are accepting Medicare part D
Patients are eligible if the medication is not covered under Medicare
Patients are eligible if Medicare coverage has been exhausted
 
Appeals
Conditions Appeals will NOT consider out-of-pocket expenses
Appeals will NOT consider total medical expenses
Appeals may be made before the patient has been denied on a case by case basis
 
Other Medications
Other
 Medications
 available in
 this program
Byetta injection 5mcg - Insulin Diabetic (Generic: exenatide)
Byetta injection 10mcg - (Generic: exenatide)
SymlinPen 60mcg - (Generic: pramlintide acetate injections)
SymlinPen 120mcg - (Generic: pramlintide acetate injections)