Rolvedon First-Cycle Patient Support Program

Funded
About
The Rolvedon First-Cycle Patient Support Program offers eligible patients in the United States the opportunity to receive Rolvedon at no cost for their first treatment cycle. Designed specifically for hospital outpatient settings, this program ensures that new patients enrolled in Access4Me can benefit from a single free dose of Rolvedon, helping to alleviate the financial burden of treatment while adhering to FDA-approved indications.
Insurance requirements: Commercially insured
Enrollment Forms
Enrollment Form
Benefits
•1 maximum fills per year
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
•FOR HOSPITAL OUTPATIENT SETTINGS ONLY
•Must be a new patient and enrolled in Access4Me to receive Rolvedon at no charge
•Limited to ONE free dose per patient
•Patient’s diagnosis is consistent with the FDAapproved indication for ROLVEDON
•ROLVEDON is administered in the outpatient setting
•Individual providers are limited to a maximum of 20 ROLVEDON units within a rolling 3month period; any single pharmacy or site of care is limited to a maximum of 70 ROLVEDON units within a rolling 3month period
•Enrollment form must be received prior to the date of injection. Replacement product for approved patients is shipped directly to the facility address where the product was administered
•Enrollment form must be received and approved prior to the date of injection
•Enroll online, by phone, or by faxing completed enrollment form to 18332817416
•Access4Me will conduct a benefits investigation, communicate the results to the office and confirm eligibility for the patient’s free dose
•Product Replacement requests need to be submitted by end of month after treatment
•Once the patient is approved, providers utilize ROLVEDON from their existing supply and submit for a free replacement unit (additional form required). No claim for ROLVEDON can be submitted to any insurer, payer or thirdparty
•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