Siliq Patient Assistance Programs

Siliq: Apply for prescription assistance below

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

Siliq Solutions Patient Assistance Program

(Program 1 of 2 — Scroll down to see them all )

Provided by: Valeant Pharmaceuticals, Inc.
Siliq Solutions Patient Assistance Program PO Box 220761 Charlotte, NC 28222-0761
TEL: 855-797-4547
FAX: 877-204-3888
Languages Spoken:
English
Program Website
Medications
  • Siliq (brodalumab)
Eligibility Requirements
  • Insurance Status Must be uninsured or unable to afford treatment
  • Those with Part D Elibible? No
  • Income At or below 400% of FPL
  • Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
  • U.S. Residency Required? The patient must be a US citizen or legal resident.
Application
  • Obtaining Call or download
  • Receiving Faxed or downloaded from website
  • Returning The completed application should be faxed back from the doctor's office.
  • Doctor's Action Complete section, sign, attach required documents
  • Applicant's Action Inform Doctor that he/she is in need
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Not specified
  • Sent To Patient's home, unless otherwise noted
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit One year
  • Re-application New application, new documentation yearly
Additional Information
Both prescriber and patient must be registered with the SILIQ REMS Program. www.SiliqREMS.com Contact program for more detail.
Updated October 15, 2018

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Patient Access Network Foundation (PAN)

(Program 2 of 2 — 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
  • Siliq (brodalumab)
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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