Program Contact Info / Application Submission
Program	Bayer Patient Assistance Program
Company	Bayer
Address	PO Box 29209, Phoenix, AZ 85038-9209
Phone	888-842-2937, opt 7, opt 3
Fax	973-305-3545
Website	N/A
Program Details
Details	Patients are sent a pharmacy card.�After six months, a form is mailed out that needs to be completed and returned.�The application process must be repeated once a year.
Program Requirements
Information	Doctors and Patient's must fill out their section and sign the application.and attach proof of income
Details	Insurance card 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 accepted 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 required 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	7-10 business days
Delivery Options
Application Process
App Process	Patients or doctors must call for a prescreening. Applications are sent to the doctor�s office. Completed applications must be mailed back. The doctor is notified of acceptance or denial. Decisions are made during the phone screening and then the application is mailed.
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 NOT apply for an appeal via phone Can apply via fax Can NOT apply for an appeal via mail
Eligibility
Eligibility	The patient cannot have prescription insurance, be ineligible for any federal or state programs and the patient must also also have limited financial resources. The patient must be a US citizen or legal US resident. Eligibility is determined on a case by case basis. Any patient who is enrolled in any Government Prescription Programs or Private Prescription Plans including, but not limited to Medicare Part D, Medicaid, State-sponsored Prescription Assistance programs, or has employee, military, retirement, or pension program drug coverage is not eligible for this program. Pharmacy discount cards or other patient assistance programs are not considered coverage
Limitations	Patients may be eligible with existing prescription coverage on a case by case basis Patients may be eligible if prescription is not covered on a case by case basis Patients are eligible if prescription coverage has been exhausted Patients are NOT eligible if they are accepting Medicare Patients may be eligible if they are accepting Medicare part D on a case by case basis Patients are NOT 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 must be made after the patient has been denied