Program Contact Info / Application Submission
Program	Amylin Reimbursement Hotline
Company	AmylinBY
Form	Download PDF
Address	PO Box 8435 Gaithersburg, MD 20898
Phone	1-800-330-7647
Website	http://www.amylin.com/products/reimbursement.cfm
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 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
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 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
Eligibility	The patient can have no insurance coverage and meet the income guidelines, which are not disclosed. In addition, the patient must be taking the medication for an on-label diagnosis. Patients must be US residents. Patients who are eligible for Part D but do 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 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 - Insulin Diabetic (Generic: exenatide)
Program Contact Info / Application Submission
Program	Amylin Reimbursement Hotline
Company	AmylinSy
Form	Download PDF
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 NOT required Drivers license required Proof of Income NOT 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) 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
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 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
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 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 - Insulin Diabetic (Generic: exenatide) symlin - (Generic: )