•Eligible commercially insured patients may pay as little as $0
•Maximum benefit of up to $2000 per calendar year
•Patient's doctor must enroll, with patient's permission, by calling 18553872824, faxing the paper application found at https://www.dalvance.com/content/pdfs/DCCopayPatientEnrollment.pdf and faxing it to 18558887206, or by enrolling online at www.DalvanceConnects.com
•Verification of benefits will be completed and provider will receive a letter outlining a patient’s eligibility and the process for accessing copay assistance
•Once patient is approved, provider will administer DALVANCE and submit the claim for DALVANCE to the patient’s insurance company
•Once the claim has been processed and paid by the insurance company, the patient or provider will submit a copy of the EOB, or the provider can submit a copy of the Remittance Advice (RA), to the program within 120 days of the administration of each dose
•Check will be issued to the provider only; it may take 45 to 60 days for the patient to receive the EOB or the provider to receive the RA form from the insurance provider
•Retroactive copay assistance is available for outpatient doses of DALVANCE administered to the patient within 120 days of patient enrollment into the program