Patient Aid Program Summary

TYPE OF FINANCIAL ASSISTANCE OFFERED: Co-Pay assistance programfor 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.

DO NOT SUBMIT BILLS FOR: Health insurance premiums, cobra payments, medical supplies/equipment/accessories, physical therapy,home healthcare, caregiving, facility parking, basic living, lost wages, travel or lodging expenses. These services are not covered in the financial assistance programs.

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 for our programs.

ENROLLMENT: Programs open for enrollment every January 1st on a first-come/firstserve basis. A new application is required each year for further assistance. Financial aid for programs is subject to the availability of funds.

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 and October 31 of following year. The deadline to receive claims within our guidelines is December 1st of each year.

TERMINATION: Enrollment in each program is automatically terminated if no claims have been submitted within a four-month period of initial enrollment date. Extensions to file claims are limited. To request a maximum of two additional months, please contact the office within the initial four-month filing period to remain enrolled.

Termination Process Steps/Deadlines

FIRST

APPLICATION APPROVAL/ENROLLMENT

Patient notified and provided claim form

NEXT

4 MONTHS FROM ENROLLMENT

First claim filed
OR
Patient contacts Patient Aid Department for 2-month extension

FINAL

APPLICATION APPROVAL/ENROLLMENT

No claims filed or extensions granted within 4 months from enrollment – Enrollment terminated

COVERED TREATMENTS AND SERVICES PRESCRIBED BY YOUR TREATING FACILITY:

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.

PRESCRIPTIONS FOR:

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-viralfungal

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

TO APPLY: Click on the Patient Aid Application page under the Patient Aid tab or request one by mail. For 2020 program doctor's signature on page 2 of application must be dated 12/2019 and after.

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