How to Apply
PAN offers two easy ways to apply for co-payment assistance:
Monday through Friday, 9 a.m. to 5 p.m. EST
The following patient information is required to complete the application:
- » Diagnosis and medication name
- » Demographics: Name, address, phone number, and e-mail address.
- » Income: Gross income applicable to the patient and all members of the patient’s household.
- » Insurance: Health insurance and pharmacy card(s).
- » Physician Demographics: Prescribing physician name, phone number, and facility address.
Applicants are required to attest that the application information provided is complete and accurate. Reported financial information may be verified by an audit, as deemed necessary by PAN.
For more information, please see our Frequently Asked Questions.