rxhelp360.org
| 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 |
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| 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 |
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