Dalvance Connects Co-pay Assistance Program
Funded
About
The Dalvance Connects Co-pay Assistance Program offers significant savings on the drug Dalvance for eligible patients. The program allows commercially insured patients to potentially pay as little as $0, providing up to $2000 in benefits per calendar year. This makes the Dalvance Connects Co-pay Assistance Program a valuable resource for patients seeking affordable access to Dalvance, administered in an outpatient care setting.
Insurance requirements: Commercially insured
Enrollment Forms
Enrollment Form
Benefits
•$2000 annual maximum benefit
Program Requirements
•Valid only for residents in the US and Puerto Rico
•Enrollment Required: Yes
•Coverage Required: No
•Needs Based: No
•Activation Required: No
Program Details
•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
Enrollment Forms
Enrollment Form
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Commercially Insured
Medicare / Medicaid
Dalvance Connects Co-pay Assistance Program - Covered benefit
Coverage Required
Commercially Insured
Max Saving: $2000/year*
Pay as low as
$0/ fill