Patient Aid Program Guide/Application

TYPE OF FINANCIAL ASSISTANCE OFFERED: The CLRA Patient Aid Program is a co-Pay assistance program for reimbursement of leukemia/blood cancer related medical bills that are listed under “Covered Treatments and Services”. Upon approval of each claim, payment will be made to the patient or guardian as applicable.

ELIGIBILITY: Programs are available for adults and children with leukemia or any type of blood cancer, residing and receiving treatment within the United States, having U.S. citizenship (SS#), or a Legal Residency or ITIN number. No proof of income is required. Medicaid recipients are not eligible.

ENROLLMENT: Applications are accepted on a first come first served basis. Please allow 2-3 weeks for application processing.

Required Documents:

  1. Doctor's verification form dated no earlier than January 2022. Have the treating physician complete the form. Do not send to CLRA. You will need it to upload the COMPLETED form into the application.
  2. Patient's Insurance Card

ASSISTANCE AND PROGRAM DATES: The maximum assistance to each patient is $3,000.00 for approved claims within the dates of service between November 1, 2021 and October 31, 2022. The deadline to receive claims within our guidelines is December 1, 2022.

TERMINATION: Enrollment is automatically terminated if no claims have been submitted within a four-month period of initial enrollment date.

Termination Process Steps/Deadlines

FIRST

APPLICATION APPROVAL/ENROLLMENT

Patient notified and provided claim form

NEXT

WITHIN 4 MONTHS OF APPROVAL DATE:

File first claim

FINAL

4 MONTHS FROM DATE OF APPROVAL

No claims filed - Program enrollment is terminated

COVERED TREATMENTS AND SERVICES PRESCRIBED BY YOUR TREATING FACILITY:

Prescriptions:

Oral chemotherapy, IVIG, immunosuppressants, preventative antibiotics, neutropenia, thrombocytopenia, pain and numbing, anti-nausea, anti-anxiety, anti-depressants, blood thinners, vitamins/minerals.

**Graft vs Host Disease: Liver/gallbladder/gastrointestinal/skin/anti-biotic-viral fungal

**We also accept these from members who do not have GVHD.

Treatments and services:

Office visits, routine exams and blood tests, other diagnostic and lab tests including those on various organs and systems used to determine how your leukemia and its treatment are affecting them.

IV chemotherapy, IVIG therapy, radiation therapy, post-bone marrow transplant therapy.

NOT COVERED:

DO NOT SUBMIT BILLS FOR: Health insurance premiums, cobra payments, medical supplies/equipment(including masks)/accessories, physical therapy, osteopath therapy, massage, acupuncture, acupressure, home healthcare, caregiving, prescription delivery fees, dentistry, optometry, facility parking, basic living, lost wages, travel or lodging expenses. Ambulance, emergency room, and hospital stays (observation, private rooms, discharge fees, hospital fees).

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