GetCopayHelp | Eligibility Check for Prescription Assistance

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Referrer

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Get Page URL

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Select the name(s) of the drug(s) you are seeking assistance for* This field is required.Click on the dropdown to type and select the drug. If your drug name is not available in the list, select Not Found

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Please enter the name of the drug you are seeking assistance forClick on 'Add Row' if you are seeking for more than 1 drug

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Are you a legal resident of United States?* This field is required. Includes citizens, green card holders, people on work, student, dependent and other types of visas, excluding tourists.

YESNO

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Where do you reside?* This field is required.Enter the name of the US state.

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What's your primary health insurance?* This field is required.

Uninsured

Medicaid

Medicare

Private / Commercial

Employer sponsored

Veteran Affairs (VA) / Tricare

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Does your insurance cover this drug?* This field is required.Select Yes, if it 1) covers fully or partially or with caveats (eg copays, coinsurance etc), 2) has covered partially or fully in the past

YESNO

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Do you have Medicare Part D plan?* This field is required.Medicare Part D plan provides coverage for prescription drugs

YESNO

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Have you ever been denied coverage for this drug by your insurance?* This field is required.Select Yes, if a) Your insurance claim was denied within the last 12 months b) Prior Authorization for this medication was denied or is still pending approval

YESNO

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What is the size of your household?* This field is required.Count all individuals and dependents who reside with you, including yourself.

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What's your monthly household income (US Dollars)?* This field is required.Include the incomes of all earning members in your household.

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How much do you spend on medical needs every month?* This field is required.Enter the amount that you pay out-of-pocket for medical and pharmacy services (doctor visits, imaging, lab, prescriptions) of the entire household.

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What's the deductible amount for your insurance plan?A deductible in health insurance is the amount you have to pay out of pocket before your insurance plan starts to cover.

You may skip this if you are not aware.

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Your request ID* This field is required.This is a system generated ID for your eligibility check. You may copy this for your reference.

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