Program Contact Info / Application Submission
Program	Berlex Patient Assistance Program Betapace
Company	BerlexBetapace
Form	Download PDF
Address	6 West Belt, W66, Wayne, NJ 07470-6806
Phone	888-237-5394
Fax	973-305-3545
Program Details
Details	A 90-day supply is shipped to the doctor’s office. Refills require a re-order form to completed by either the doctor or doctor's office. A new application with documentation is needed once a year.
Program Requirements
Information	The doctor must fill out their section and sign the application. Patients must fill out their section, sign the application and attach proof of income.
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 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
Ship Time	7-10 business days
Delivery Options	Can NOT be delivered directly to the patient Can be delivered directly to the doctor
Application Process
App Process	Patients or doctors can call to request an application. Applications are sent to the doctor’s office. Completed applications can either be faxed or mailed back.
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 apply for a new application via fax Can apply for a new application via mail
Refills	Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can 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 can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals NOT accepted Hardship Appeals NOT accepted
Eligibility
Eligibility	Patients who are interested in this program cannot have any prescription insurance, must be ineligible for any government programs and have a low income based on the Federal Poverty Guidelines. Patients who are enrolled in any Government Prescription Programs or Private Prescription Plans, (such as; Medicare Part D, Medicaid, State-sponsored Prescription Assistance programs, employee insurance, military, retirement, or pension programs with drug coverage) is not eligible for this program. All applicants must be a US citizen or legal US resident. Each applicant is handled on a case-by-case basis.
Limitations	Patients are NOT eligible if LIS is denied 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 NOT 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 NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses