Referrals to the Esbriet Co-pay Program
Co-pay programs provide direct financial assistance to patients to help with their co-pays, co-insurance or other out-of-pocket costs. If eligible commercially insured patients need assistance with their out-of-pocket costs, Esbriet Access Solutions can refer them to the Esbriet Co-pay Program.
Patients who qualify can receive up to $25,000 in assistance per 12-month period. They pay $5 per drug co-pay or co-insurance until the annual limit is reached.
To get started, call (877) 780-4958 or visit EsbrietCopay.com.
The Esbriet Co-pay Program is available only for commercially insured patients. Patients using Medicare, Medicaid or any other government-funded program to pay for their medications are not eligible. It requires a valid, on-label prescription and cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription. It is available only for a patient (or their guardian) who is 18 years or older. It is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other health care or pharmaceutical assistance programs that reimburse the patient in whole or in part for the medication. It is valid only for Genentech products in the United States and Puerto Rico. The Esbriet Co-pay Program is not health insurance or a benefit plan. Please see full terms and conditions at EsbrietCopay.com.
PAN=Patient Authorization and Notice of Request
for Transmission of Health Information to Genentech Access Solutions
and Genentech® Access to Care Foundation.
SMN=Statement of Medical Necessity.