Dalvance Connects Co-pay Assistance Program - Covered benefit

Coverage RequiredFunded

About

The Dalvance Connects Co-pay Assistance Program - Covered benefit offers significant financial support for eligible patients prescribed Dalvance. With this program, patients may pay as little as $0 and receive up to $2000 in benefits per calendar year. The Dalvance Connects Co-pay Assistance Program is ideal for those with private insurance seeking cost-effective treatment options.

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: Yes

•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

•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