| |
Program Details
AMGEN, INC.
Amgen By Your Side - Actimmune
Actimmune
(interferon gamma-1b)
|
| CONTACT
INFO |
|
| Address: |
1 Horizon Way
Deerfield, IL 60015 |
| Phone: |
1-877-305-7704 |
Provider Phone: |
|
| Fax: |
1-877-305-7706 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Eligibility determined on a case-by-case basis.
Patients with Medicare Part D may be eligible, contact program for details.
Income based on Federal Poverty Level.
|
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
Not
Published |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
Copy of DEA or State License number
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Not Published
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Varies
|
| Quantity in
Shipment: |
Varies |
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients. |
|
|
Last Updated: 03/28/2025
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Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
|
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