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Cromolyn sodium Patient Assistance Programs

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Looking for a different medication?

Enter your medication below:

Or go to the main Patient Assistance Programs page>>

: Apply for prescription assistance below


If you are eligible, the programs below can help you afford . Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.


If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.



Xubex Patient Assistance Program


(Program 1 of 4. Scroll down to see them all.)

Provided by: Xubex
PO Box 1244 Winter Park, Fl 32790-1244

TEL: 866-699-8239
ALT PHONE: 407-478-2663
FAX: 407-671-7960
Languages Spoken:
English
Program Website
 

Program Applications and Forms

  • Xubex Patient Assistance Program Physician Order Sheet (page 3) (PDF)
  • Xubex Patient Assistance Program Registration Form (pages 1 & 2) (PDF)

Medications

Eligibility Requirements   
Insurance Status May have insurance
Those with Part D Eligible? Yes, but contact program for details
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? The patient must also be a US resident.

Application
Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning The completed application can be faxed or mailed back.
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified

Medication
Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Varies per medication
Re-application New application, new documentation yearly

Additional Information
No proof of income is required. Check the website for the exact price. This service is not currently available in Montana.

Updated 10/31/2016

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HealthWell Foundation Copay Program


(Program 2 of 4. Scroll down to see them all.)

Provided by: HealthWell Foundation
PO Box 220410 Chantilly, VA 20153-0410

TEL: 800-675-8416
FAX: 800-282-7692
Languages Spoken:
English, Others By Translation Service
Program Website
 

Program Applications and Forms

  • HealthWell Foundation Copay Program: Contact program

Medications

Eligibility Requirements   
Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? The patient must also be residing in the US.

Application
Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning The completed application must be mailed back.
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days

Medication
Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months

Additional Information
This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease. Call for most recent medications as the list is subject to change.

Updated 11/18/2016

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HealthWell Foundation Copay Program


(Program 3 of 4. Scroll down to see them all.)

Provided by: HealthWell Foundation
PO Box 220410 Chantilly, VA 20153-0410

TEL: 800-675-8416
FAX: 800-282-7692
Languages Spoken:
English, Others By Translation Service
Program Website
 

Program Applications and Forms

  • HealthWell Foundation Copay Program: Contact program

Medications

Eligibility Requirements   
Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? The patient must also be residing in the US.

Application
Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning The completed application must be mailed back.
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days

Medication
Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months

Additional Information
This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease. Call for most recent medications as the list is subject to change.

Updated 11/18/2016

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Patient Access Network Foundation (PAN)


(Program 4 of 4. Scroll down to see them all.)

Provided by: Patient Access Network Foundation
PO Box 221858 Charlotte, NC 28222-1858

TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
 

Program Applications and Forms

  • Patient Access Network Foundation (PAN) Application: Contact program

  • Patient Access Network Foundation (PAN) Patient Brochure (PDF)
  • Patient Access Network Foundation (PAN) Provider Brochure (PDF)

Medications

Eligibility Requirements   
Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US

Application
Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours

Medication
Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months

Additional Information
*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.

Updated 8/2/2016

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