Financial Assistance Forms

Annual recertification of eligibility to participate in the 340B program. Failure to complete results in program termination. Authorizing Official must verify compliance with all program requirements.

Required within 60 days if HRSA audit findings are accepted. Documents corrective measures for compliance issues identified during program audit. Non-submission may result in removal from the 340B program.

Online registration in the 340B Office of Pharmacy Affairs Information System. Required for covered entities (FQHCs, hospitals, etc.) before purchasing 340B-priced drugs. Requires supporting documentation for hospital classification.

Application for Extra Help (Low-Income Subsidy) with Medicare Part D prescription drug costs. Reduces premiums, deductibles, and copayments for qualifying beneficiaries. Can save an average of $5,300 per year.

Enrollment for manufacturer copay reduction programs for commercially insured patients. NOT available to Medicare, Medicaid, or other federal program beneficiaries. Some insurers have accumulator adjustment programs that prevent copay card amounts from counting toward deductible.

Applications for disease-specific foundation assistance programs that help with medication costs, insurance premiums, and copayments. Foundations include HealthWell, PAN Foundation, Patient Advocate Foundation, and others.

Attestation that the Patient Assistance Program operates outside the Part D benefit to ensure separateness. PAP assistance does not count toward True Out-of-Pocket costs (TrOOP).

Application for free or reduced-cost medications for uninsured or underinsured patients. Requires income documentation and prescriber attestation. Each manufacturer has its own form and eligibility criteria.

Application for state-funded prescription drug assistance. Eligibility typically based on age, income, and residency. Available in 20+ states. May coordinate with Medicare Part D for additional savings.