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Celgene
Understanding Insurance Coverage and Reimbursement

Forms

Did you know that 4 out of 5 patients who requested assistance from Celgene Patient Support® received their medication? We have helped more than 15,000 patients since 2007.

The forms you may need when seeking help are provided below. Before getting started, please contact us at 1-800-931-8691. Depending on the type of help you need, your dedicated Celgene Patient Support® Specialist may ask you to complete these forms:

› Patient Assistance Application
› Appointment of Representative Release Form
› Medicare Low-Income Subsidy ("Extra Help") Form

These forms are provided in PDF format. Click on the form to download a PDF. You can type in the form, print it out and sign it. Or, you may print out the form and write in it. To download these forms, you must have Adobe® Reader® on your computer. If you do not have this program, click here to download it for free.

Patient Assistance Application

Your Celgene Patient Support® Specialist may ask you to complete the Patient Assistance Application if:

  • You are applying for the Celgene free medication program, or
  • Your insurance company has denied coverage for your Celgene medication and you need to file an appeal
The Patient Assistance Application has two parts: one for you to complete, and one for your doctor to complete. Your Celgene Patient Support® Specialist can help you complete this form. Call us at 1-800-931-8691.
Download now

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Appointment of Representative Release Form

The Appointment of Representative Release Form is needed so that we may help with appeals upon a denial from your insurance company. By completing this form, you are allowing Celgene Patient Support® to call your insurance company and ask questions on your behalf. Your Celgene Patient Support® Specialist can help you complete the Appointment of Representative Release Form. Call us at 1-800-931-8691.
Download now

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Medicare Low-Income Subsidy ("Extra Help") Form

Your Celgene Patient Support® Specialist may ask you to complete the Medicare Low-Income Subsidy ("Extra Help") Form to see if you qualify for a Medicare low-income subsidy. The low-income subsidy provides extra help in paying for prescription drug costs. Your Celgene Patient Support® Specialist can help you complete this form. Call us at 1-800-931-8691.

*You may complete this form on the Medicare website. Click here to access this form.

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For more help, contact Celgene Patient Support® at 1-800-931-8691. Your Celgene Patient Support® Specialist is a dedicated, central point of contact who will work on your behalf to coordinate resources available to you. Together we will exhaust all options to help you get the information and support you need.

Need more help?

Contact us at 1-800-931-8691 or send us an e-mail.

To get started, call us at 1-800-931-8691

Your Celgene Patient Support® Specialist may ask you to complete a Patient Assistance Application

Click here to access this form

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Assistance

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Questions About My Prescription

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