How the Program Works

Please click on "Locations" to find the program closest to you.

• To refer a patient, physician/prescriber must complete and submit a Referral Form to MEDBANK.
  Referral Form (MS Word format)
  Referral Form (PDF format)
   
• Physician/prescriber and patient complete a referral form, including a list of the patient's prescribed medications (Brand Name Only)
  
• Patient provides proof of income and insurance information to MEDBANK to verify eligibility.
  
• Patient must sign a consent/authorization form.

View List of Medications with Programs OR List of Medications by Class*
* Note: To download any of the above forms you need Acrobat Reader. Click the logo for a free download.

• MEDBANK Program representative identifies Patient Assistance Programs for the patient, completes applications and where required obtains written prescriptions from physician - and patient and/or physician signatures.
  
• Most pharmaceutical companies will ship a 90-day supply to the physician's office.
  
• Patient notifies the MEDBANK Program representative when medications are received and the MEDBANK Program representative repeats applications.

			Patient Application Requirements

• Patient demographic information
• Social Security number or green card
• Verification of income (tax return, pay stubs)
• Statement of benefits (Award) letter from Social Security
• List of medications (Brand Name medications only)
• List of assets (home, savings, checking, CD's, IRA's, etc.)

Note: The process can take 6-8 weeks. Talk with your physician or health care professional about what to do until your medication arrives.

For additional questions please call us or read the Frequently Asked Questions section.
 

			Company Programs & Medicare Part D

Medicare Part D Patient Assistance Program Status