rxhelp360.org
| Program Contact Info / Application Submission | ||||||
| Program | Biovail Patient Assistance Program | |||||
| Company | BIOVAIL | |||||
| Form | Download PDF | |||||
| Address | PO Box 836 Somerville, NJ 08876 | |||||
| Phone | 866-268-7325 | |||||
| Program Details | ||||||
| Details | Up to a 90-day supply is sent to the doctor's office. A new application with new prescription is needed for refills. Once a year a new application with financial documentation is needed. | |||||
| Program Requirements | ||||||
| Information | The doctor must fill out a section, sign the application and attach a prescription for 90 days. The patient must fill out a 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 income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements 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 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 | 4-6 weeks | |||||
| Delivery Options | Can NOT be delivered directly to the patient Can be delivered directly to the doctor | |||||
| Application Process | ||||||
| App Process | With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application must be mailed back. Both the patient and doctor are notified in writing of acceptance or denial. The medication is shipped out within 5-7 business days. | |||||
| New Applications | New applications accepted Patients 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 | |||||
| Refills | Refills accepted Patients can NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can NOT apply for refills via phone Can NOT 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 NOT Re-Apply via fax Can Re-Apply via mail | |||||
| Appeals | Income Appeals accepted on a case by case basis Patients can NOT apply for Income Appeals Doctors can 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 NOT apply for an appeal via fax Can NOT apply for an appeal via mail | |||||
| Eligibility | ||||||
| Eligibility | The patient must have no prescription coverage for any medications and have an income at or below 200% of the Federal Poverty Level. The patient must also be a US resident. If a patient enrolls in Medicare Part D, then s/he is no longer eligible for this program. If the patient chooses not to enroll in Part D, then s/he is still eligible to be on this program. There is some assistance available for Vasotec, call the company for more details | |||||
| 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 | |||||
| Other Medications | ||||||
| Other Medications available in this program |
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