Patient assistance
May provide ZYMFENTRA at no cost to eligible uninsured or functionally uninsured patients with household income at or below 400% of the federal poverty level.
What it does
Evaluates insurance exhaustion, household income, prescription, residence, alternate-funding status, and other eligibility. Benefits are rechecked every six months.
Open official program pagePotentially available to eligible adults who are uninsured or functionally uninsured after attempting all coverage options, have household income at or below 400% FPL, and meet residence and funding rules.
Government program exclusions: Government coverage when excluded by current terms, Alternate funding programs
Complete and sign the patient section of the current application.
Open documentReview the official eligibility page, then patient and prescriber complete the assistance application and submit income, insurance-exhaustion, authorization, and prescription information.
Best for: Services requiring clinical information, a prescription, or prescriber attestation
Patient completes demographics and the authorization/consent section of the official form.
Owner: Patient
Have ready: Contact information, Signature and date
Patient, Prescriber And Clinic Staff, Celltrion CONNECT
Celltrion CONNECT
Enrollment, savings, benefits, authorization, temporary access, Nurse Connector, and patient assistance.
Monday-Friday, 8 AM-8 PM ET
Official patient-assistance eligibility page.
Provide requested household-income records.
Provide denials or other evidence that available coverage options were attempted.
Complete the provider application and valid prescription.
Prescriber completes the prescription, clinical, insurance, and service-selection sections and attaches supporting records.
Owner: Prescriber or clinic staff
Have ready: Patient authorization, Income evidence when requested, Insurance exhaustion evidence, Provider section, Prescription
Submit the completed form by fax to 1-833-912-3707.
Owner: Clinic staff
Best for: Patients who may be uninsured or functionally uninsured
Provide the requested prescription, insurance, contact, and consent information.
Owner: Patient or caregiver
Have ready: Prescription details, Insurance card, Prescriber contact information
After enrollment: The program communicates approval and dispensing instructions. Electronic income verification can reduce documentation unless a mismatch occurs.
If there is a problem: Call to identify missing income, insurance-exhaustion, alternate-funding, provider, or prescription information.
Official application form for ZYMFENTRA patient assistance.
Official combined enrollment form with three submission paths.
