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You Are Currently Enrolling Online for Celgene Patient Support

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3 Items You Will Need to Complete This Form:

  •  Patient InformationIf applying for co-pay assistance or Celgene Patient Assistance Program (PAP), the patient’s gross family income and number of people living in their household will need to be provided.
  •  Physician Information
  •  Health Insurance Information (If Available)

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Please select all of the services you are looking for.

  • Helps patients understand their insurance coverage and co-pays; assesses patient eligibility for Medicare, Medicaid, or alternative coverage
  • Assists patients who have commercial or private insurance but are unable to afford their co-pay
  • Expedites the process of authorizing the use of a Celgene product prior to initiating therapy
  • Helps appeal the denial of a prior authorization/pre-certification or claim for a Celgene product

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The following required fields have been left blank:


Drugs & Diagnosis


Caregiver Information

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The following required fields have been left blank:

  • Part A (Hospital)
    Part B (Medical)
    Part D (Drug Coverage)

Insurance Company Information


Prescription Coverage Information

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The following required fields have been left blank:

Physician Information


Facility Information

Revlimid® (lenalidomide), Pomalyst® (pomalidomide) and Thalomid® (thalidomide) only

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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The following required fields have been left blank:

Patient Financial Information

This information is required to determine eligibility for financial assistance. Patients may be subject to a random audit to verify their gross annual household income.
  • (Number of people who contribute to or are dependent on your household income)
  • (Value should reflect amount for entire household. Gross household income is the total income before income tax deductions from all people living in your household. Gross income refers not only to the salaries and benefits received, but also to the receipts from any personal business, investments, dividends, and other income.)
    $

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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Add Additional Files

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You Are Almost Done

To submit this form, please read the user statement and agree to the terms. Finalize this form by entering your first and last name as your signature.

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.

User Confirmation Statement

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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A Patient Support Specialist is Available to Help

REVLIMID® (lenalidomide), POMALYST® (pomalidomide), and THALOMID® (thalidomide) are only available through restricted distribution programs.

Please see full Prescribing Information, including Boxed WARNINGS, for REVLIMID®, POMALYST®, THALOMID®, IDHIFA® (enasidenib), and ABRAXANE® for Injectable Suspension (paclitaxel protein-bound particles for injectable suspension) (albumin-bound). Please see full Prescribing Information for  VIDAZA® (azacitidine for injection).

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The ICD-10-CM Codes provided here are for diagnoses reasonably related to an indication or indications within the product’s approved label and are provided for your reference only. Other codes may be appropriate. Celgene makes no representation that any code is appropriate for a particular patient. Healthcare Professionals must use their independent judgment in selecting Code(s) to accurately reflect the diagnosis of the specific patient.

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Peter
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Celgene Patient Support® Specialist
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Peter
Peter is a Celgene Patient Support® Specialist for Zip Code .

If this is not your doctor's zip code, click the zip code link above.

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