Celgene Patient Support Specialist
Samantha Feula

Samantha is a Celgene Patient Support® Specialist for zip code 20149. If this is not your zip code, click here.

PhoneFor more information, call 1-800-931-8691

Welcome

Celgene Patient Support® is committed to using our best efforts to protect your privacy. While the security of information in transit over the Internet cannot be assured, our privacy practices are designed to protect personally identifiable information and to ensure that we use information we receive in ways compatible with the purposes for which it has been collected. All the information provided in this online enrollment form will be sent in an encrypted form and then stored in a secure Celgene Database.

The information provided is for Celgene Patient Support® use only and will not be shared outside of Celgene Patient Support® and its authorized representatives, agents, and individuals or entities involved in processing this application and implementing a Celgene Patient Support® program for which you may qualify. These may include your Healthcare Professional and health insurance provider. If you have questions about the privacy of your information, e-mail privacy@celgene.com or write to Celgene Corporation, 86 Morris Avenue, Summit, NJ 07901. Attention: Privacy Office.

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Services

Please select all of the services you are looking for.

  • Benefits Investigation
    Helps patients understand their insurance coverage and co-pays; assesses patient eligibility for Medicare, Medicaid, or alternative coverage
     


  • Appeals Assistance
    Helps appeal the denial of a prior authorization/pre-certification or claim for a Celgene product
     


  • Celgene Commercial Co-pay Program
    Assists patients who have commercial or private insurance but are unable to afford their co-pay
     


  • Prior Authorization/Precertification
    Expedites the process of authorizing the use of a Celgene product prior to initiating therapy
     


  • Co-payment/Co-insurance Assistance
    Helps patients apply for co-pay assistance programs from non-profit 501 (c) (3) foundations when they are unable to afford their co-pay
     


  • Celgene Free Medication Program
    Determines the eligibility of uninsured and underinsured patients for the Celgene Free Medication Program based on patient financial and insurance criteria
     


Referral Source

  • Patient
    Caregiver
    Healthcare Professional
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Patient Information

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  • Yes No
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  • Male Female
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    MM / DD / YYYY
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Drugs & Diagnosis

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Caregiver Information

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Patient Insurance Information

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  • Part A
    Part A (Hospital)
    Part B
    Part B (Medical)
    Part D
    Part D (Drug Coverage)
    Medicare Advantage I Don't Know
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Healthcare Professional Information

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Physician Information

Facility Information

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FAST TRACK FOR FIRST PRESCRIPTION®
Revlimid® (lenalidomide), Pomalyst® (pomalidomide) and Thalomid® (thalidomide) only

This service expedites your patient's first prescription for REVLIMID®, POMALYST®, or THALOMID®. To enroll in this Celgene Patient Support® service, you must: 1) have a complete and signed first prescription, 2) be registered in the Celgene Risk Evaluation and Mitigation Strategy (REMS) program, and 3) have a valid authorization number. For more information, call 800-931-8691.

  • Yes
    No

Please be sure to upload the patient's prescription (Rx) on the next screen or fax it to the Celgene Patient Support® team at 1-800-822-2496.

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Eligibility & Documentation

This information is required to determine eligibility for Co-payment/Co-insurance Assistance,
Celgene Commercial Co-pay Program, and Celgene Free Medication Program.

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Patient Financial Information

  • (Number of people who contribute to or are dependent on your household income)

  • (Value should reflect amount for entire household)
    The combined income of all members of a household before tax.
    $




    Monthly    Yearly

Please check all that apply:

  • Salary/Wages

  • Pension

  • Earnings from Dividends

  • Disability

  • Social Security

  • Earnings from Rental Property


Documentation

Additional documentation may be requested by your Celgene Patient Support® Specialist following the submission of this form. For your convenience, you can also upload this information below. If you are unable to upload the documents at this time, you may fax them directly to the Celgene Patient Support® team at 1-800-822-2496.

Documentation Type

  • Please select your document type from the list below. To select multiple document types, Hold “Ctrl” button while selecting each item. If you cannot find your document type in the provided list, please select “Other” and enter your Document Type in the “Other field.”



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Confirm & Submit

Protecting your confidential information is very important to us. All information provided to Celgene Patient Support® will be encrypted and secured. If you have any questions regarding this electronic application, please call 1-800-931-8691.

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User Confirmation Statement

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