Program Contact Info / Application Submission
Program	Betaseron Foundation
Company	BayerNex
Form	Download PDF
Address	MS Pathways, PO Box 221349, Charlotte, NC 28222
Phone	877-836-5724
Fax	877-744-5615
Website	http://www.betaseronfoundation.org
Program Details
Details	A 30-day supply is shipped to the patient�s home.�Patients must contact the company to arrange for refills.�A new application with documentation is needed once a year.
Program Requirements
Information	The doctor must fill out thier section, sign the application and attach a valid prescription.�The patient must fill out their section, sign the application and attach proof of income along with any insurance information if applicable.
Details	Insurance card 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 income accepted 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
Other Requirements	$5.00 - $35.00 co-pay for each shipment
Delivery of Medication
Delivery Options	Can be delivered directly to the patient Can NOT be delivered directly to the doctor
Application Process
App Process	Doctors or patients can call and request an application. Applications are faxed out. 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 NOT apply for refills Advocates can NOT apply for refills
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
Eligibility
Eligibility	Patients must meet insurance and�income guidelines that are not disclosed.�They must also have MS and be a US resident.�This program has a support hotline with registered nurses and counselors who are available 24 hours a day, seven days a week. Training is also available if needed.
Other Medications
Other  Medications  available in  this program	Betaseron SC Injection 0.25mg (1cc) (interferon be - (Generic: )