Imlygic Patient Assistance Programs

Imlygic: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Imlygic. 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.

Looking for a different medication?

HealthWell Foundation Copay Program

(Program 1 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
Medications
  • Imlygic (talimogene laherparepvec)
Eligibility Requirements
  • Insurance Status May have insurance
  • Those with Part D Elibible? Yes
  • Income Varies
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. 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 Proces 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 November 1, 2018

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Amgen Safety Net Foundation

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

Provided by: Amgen, Inc.
None
TEL: 888-762-6436
Languages Spoken:
English, Spanish
Program Website
Program Applications and Forms
Medications
  • Imlygic (talimogene laherparepvec)
Eligibility Requirements
  • Insurance Status Must be uninsured or underinsured
  • Those with Part D Elibible? Varies
  • Income At or below 500% of FPL
  • Diagnosis/Medical Criteria *See Additional Information section below
  • U.S. Residency Required? Yes, must have lived in the US or its territories for 6 months or longer.
Application
  • Obtaining Call or download from Programs website
  • Receiving Mailed or downloaded from website
  • Returning The completed application must be faxed or mailed from the doctor's office.
  • Doctor's Action Complete section, sign, attach required documents
  • Applicant's Action Complete section and sign
  • Decision Communicated Patient and Doctor are notified
  • Decision Timeframe Varies
Medication
  • Amount/Supply Amount requested is sent
  • Sent To Address of shipment varies by medication
  • Delivery Time Varies
  • Refill Proces Determined on a case by case basis
  • Limit Not specified
  • Re-application Varies
Additional Information
Please visit www.SafetyNetFoundation.com for more information or visit www.AmgenAssist360.com for product information. * Diagnosis is required if patient has insurance.
Updated September 28, 2018

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Amgen FIRST STEP Co-Pay Support

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

Provided by: Amgen, Inc.
None
TEL: 888-657-8371
FAX: 888-653-2972
Languages Spoken:
English
Program Website
Program Applications and Forms
Medications
  • Imlygic (talimogene laherparepvec)
Eligibility Requirements
  • Insurance Status Must be commercially insured
  • Those with Part D Elibible? No
  • Income Not Required
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? The patient must also be a US citizen.
Application
  • Obtaining Patient/Doctor must call to register and enroll
  • Receiving Not applicable
  • Returning The completed application's destination is not applicable
  • Doctor's Action Enroll in program, complete form and obtain patient consent
  • Applicant's Action Call to enroll
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Not applicable
  • Sent To Card sent to doctor's office or to patient's home
  • Delivery Time Not specified
  • Refill Proces Doctor/Doctor's office must contact the Program
  • Limit None
  • Re-application Card is valid for the enrolled patient's entire course of treatment
Additional Information
Health Care Providers must enroll in the program prior to processing the Amgen FIRST STEP Program Cards The card is valid for the patient's entire course of treatment. Eligible patients may re-enroll at any time a new course of treatment is initiated.
Updated September 26, 2018

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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
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Imlygic (talimogene laherparepvec)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. 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 Proces 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 July 10, 2018

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