Rolvedon Copay Assistance Program

Funded

About

The Rolvedon Copay Assistance Program is designed to help patients reduce their out-of-pocket costs for the drug Rolvedon. With this program, eligible patients with commercial or private insurance can potentially pay $0 per dose of Rolvedon, with an annual benefit cap of $15,000. The program ensures access to necessary treatment through manageable financial avenues, reinforcing its commitment to patient care.

Insurance requirements: Commercially insured

Enrollment Forms

Enrollment Form

Benefits

•$15000 annual maximum benefit

•12 maximum fills per year

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Must be 18 years of age or older

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: No

•Activation Required: No

Program Details

•Patients with commercial or private insurance may pay $0 outofpocket costs for each ROLVEDON dose

•Must have a copay for Rolvedon

•Maximum annual benefit of $15,000 per 12month enrollment period

•Patient and HCP must complete form and fax to 18332817416; or electronic submission visit www.Access4Me.com. Please note: Patient and provider signatures are required for processing

•Upon approval, the copay card is activated and shipped directly to the provider or injection center

•For questions about applying for coverage, program eligibility criteria, or denied claims, call Access4Me at 8665822737 (86658CARES) 8:00 AM to 8:00 PM (ET), Monday Friday

Enrollment Forms

Enrollment Form