Rolvedon Patient Assistance Program

Funded

About

The Rolvedon Patient Assistance Program provides an opportunity for patients to receive the drug Rolvedon at no cost if they are uninsured or underinsured. This program, known as the Rolvedon Patient Assistance Program, requires the completion of a form by the patient and healthcare provider, ensuring a seamless process for applicants. With the Rolvedon Patient Assistance Program, eligible patients can access vital medication without the burden of financial strain.

Insurance requirements: Underinsured, Uninsured

Enrollment Forms

Enrollment Form

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: Yes

•Activation Required: No

Program Details

•Patients who are uninsured or underinsured may be eligible to receive ROLVEDON at no cost through the Patient Assistance Program

•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

•Access4Me will independently verify patient income; if the income validation tool is unable to return results, the patient will be required by Access4Me to provide proof of income; proof of income may also be requested at any time for audit/verification

•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