Online Enrollment Application


Frequently Asked Questions

Application process

1. Who is eligible for medication co-payment assistance from PAN?
2. How do I apply?
3. How do I send in my application?
4. What income documentation do I need?
5. What forms do I need from my doctor?
6. How long does approval take and how will I know I'm approved?

PAN Assistance Once You Have Been Approved

1. When does my assistance start?
 2. How much assistance will I receive?
 3. Will you cover all the costs for my treatment?
 4. How much will this cost me?
 5. Who gets the actual payment from PAN?
 6. How do I submit a claim?
7. How can I find out how much of my benefit I have left?
8. How do I use the pharmacy card?
9. What about expenses before I got help from PAN?
 10. What if I change doctors or medications?
 11. Is my assistance renewable?

Application Process

1. Who is eligible for medication copayment assistance from PAN?

To qualify, you must meet our eligibility requirements:

  1. You must have been diagnosed with a disease for which PAN has a fund.
  2. The medication for which you are seeking assistance must fight the disease directly.
  3. You must be insured and your insurance has to cover the medication for which you are seeking assistance.
  4. You are prescribed a high cost drug, depending on individual fund requirements.
  5. You reside and receive treatment in the US.
  6. Your income must be below a designated percentage of the Federal Poverty Level, depending on individual fund requirements. (Click here for Federal Poverty Guidelines)

2. How do I apply?

All patients are required to complete a pre-screening. Click here to begin that process by answering basic questions online. You will need your most recent income documentation, your insurance cards, and your doctor's information. Once you have passed the pre-screening, you will be linked to the application form that you can download for your records. PAN staff will coordinate your physician's form.

OR

Call toll-free at 1-866-316-PANF (7263) to speak with a case manager (English or Spanish speaker) who can help you through the application process and answer any questions. The case manager will ask some simple questions to determine if you qualify. If you qualify, you can authorize PAN case workers to virtually sign the application on your behalf. If you are not comfortable with virtual signature, we will mail a pre-filled application for you to sign. Complete that application and mail it or fax it to PAN along with your income documentation, if you have them readily available. We will fax the physician's attestation form directly to your treating provider's office for their completion.

3. How do I send back my application?

You may mail your application and supporting documents to:

PAN Foundation
P.O. Box 221858
Charlotte, NC 28222-1858

OR

You may fax your application and supporting documents toll-free to 1-866-316-7261.

4. What income documentation do I need?

PAN accepts the following income documentation:

  1. Federal Tax Return
    • Please submit a copy of your most recent federal tax return (form 1040, 1040A, or 1040EX)
  2. Social Security Income Documentation for all household members (including dependent children or adults):
    • Copy of your Social Security or Social Security Disability award letter, or
    • Copy of bank statement showing direct deposit of benefits, or
    • Copy of your Social Security check, or
    • Copy of your SSA-1099 form
  3. Other Acceptable Income Documentation (You may submit this information if you did not have your tax return or provide it as supplemental documentation if the income on the tax return no longer reflects the patient's current household income):
    • Copy of your pension award letter, or
    • Copy of last three consecutive pay stubs, or
    • Copy of W-2 forms, or
    • Copy of Unemployment Award Letter
    • Copy of Unemployment pay stubs
    • Letter from your employer stating your monthly or annual income, or
    • Copy of your child support order, or
    • Copy of your alimony decree, or
  4. Copy of deposits/ checks showing the amount of alimony or child support. If you are self-employed and do not file a federal tax return (annually or quarterly), you can submit the following documentation verification:
    • Monthly profit and loss statements for the last 3 months
    • Bank statement showing deposit information. Please be advised that if you submit a bank statement as documentation, all deposits will count towards your income.

PLEASE NOTE: If other individuals live in your household and contribute to the household expenses, you must also submit their income information.

5. What forms do you need from my doctor?

Your physician must complete the one-page form which is part of the application. He/she needs to sign and date the form and return verification of your diagnosis and prescribed medications to PAN by mail, provider portal or fax.

6. How long does approval take and how will I know if I'm approved?

Once PAN receives your fully completed application and documentation, we will have an answer for you by the business day. If you qualify for assistance, PAN will send you an approval letter including important details such as your award amount and your eligibility dates. You will also receive a separate letter that will contain a plastic pharmacy card to be used for any qualifying prescription drugs. We will notify your doctor of your approval by fax.

If your application is not approved, we will make every effort to contact you by phone to explain the reasons for denial.

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PAN Assistance Once You Have Been Approved

1. When does my assistance start?

Assistance starts on your approval date and continues for 12 month. Your exact eligibility dates and grant amount will be included in your approval letter, and are also available at any time using our automated telephone system.

During your first eligibility period eligible expenses incurred up to 90 days prior to your approval date may also be submitted for reimbursement.

2. How much assistance will I receive?

Grant amounts range from $1500 to $15,000 per year, depending on diagnosis. The amount awarded differs for each diagnosis and is listed on the Web page for each disease fund. Your approval letter will also contain this information.

3. Will you cover all the costs for my treatment?

PAN Foundation can consider for payment any co-payment, deductible, or co-insurance amount for medications that are used to treat the disease for which you have been awarded assistance. Medications that treat the side effects of your diagnosis are not covered, and charges for office visits and administration are not typically covered.

During your first eligibility period eligible expenses incurred up to 90 days prior to your approval date may also be submitted for reimbursement.

You are free to change your medication, doctor, or pharmacy at any time without affecting your eligibility for assistance.

4. How much will this cost me?

There is no charge for services from PAN Foundation.

5. Who receives actual payment from the PAN?

Payment can be made to the physician, pharmacy or health care provider who supplies the treatment. In the case where a patient has paid out of pocket for eligible expenses, reimbursement will be paid directly to the patient.

6. How do I submit a claim?

Patients, physicians, hospitals and pharmacies may submit requests for reimbursement to PAN for covered medications related to the patient's disease. The patient's primary insurance must be billed before the claim can be submitted to PAN, and the primary insurance must consider the charge to be an eligible expense. Charges incurred within 90 days prior to the eligibility date will be considered for payment during the first year of PAN coverage. The 90-day look-back period will also apply to renewal patients after 18 months of coverage. All eligible expenses must be submitted within 120 days of the eligibility end date.

  1. If you are a patient, you may submit your request for reimbursement directly to PAN and you must provide a completed and signed Proof of Expenditure form. In addition, you must submit following:
    • Itemized provider statement, which includes the primary insurance payment, adjustment, and amount of patient responsibility. If the provider statement does not include this information, you can provide the corresponding Explanation of Benefits form;
    • Prescription label indicating the patient's co-payment amount;
    • Receipt showing payment for the services being requested for reimbursement

      Mail the information to Patient Access Network, P.O. Box 221858, Charlotte, NC 28222-1858 or fax to 866-316-7261.
      You may request reimbursement for charges that you have paid out of pocket or you may ask that PAN issue payment directly to the provider of services.

      Click here to view and/or print the Proof of Expenditure form and Patient Billing Instructions
  2. Physicians may click here to view and/or print the PAN Foundation Provider Billing Guide for billing instructions.
  3. Hospitals should submit a UB04 with the corresponding Explanation of Benefits (EOB) to PAN for reimbursement of eligible expenses.
    Billing may be mailed to the Patient Access Network P.O.Box 221858 Charlotte, NC 28222-1858 or faxed to 866-316-7261.
  4. Pharmacies may bill PAN electronically as the secondary or tertiary payer for covered medication services. The patient will receive a PAN benefits card with the patient ID number, RX group number, and Rx BIN number which they will present for payment. If the patient does not have their benefit card, pharmacies may contact PAN toll-free at 1-866-316-PANF (7263), ext. 72244 Monday-Friday, 9am-5pm Eastern Standard Time for electronic billing assistance.

    Pharmacies that don't have the ability to bill electronically may submit a CMS-1500 claim form with the corresponding Explanation of Benefits (EOB) or an itemized invoice. The itemized invoice should contain the patient name and address; the name of the medication and the charge; the primary insurance payment and any applicable insurance adjustment; the patient responsibility amount (deductible, coinsurance); and the amount paid by the patient (if applicable) on the billed charges. Billing may be mailed to the Patient Access Network, P.O. Box 221858, Charlotte, NC 28222-1858 or faxed to 866-316-7261.


7. How do I know the amount of benefits I have left?

You can determine the balance left on your account by calling 866-316-PANF (7263) and selecting the self-service option. In order to access the system you can enter either the patient's PAN ID number or the patient's Social Security Number and their date of birth. You may use this voice response system at any time - 24 hours a day any day of the week. If you wish to speak to a case manager about your balance, you may dial 866-316-PANF (7263) Monday - Friday, 9 a.m. - 5 p.m. Eastern Time and someone will assist you.

8. How do I use the pharmacy card?

You will receive a pharmacy benefits card that lists your ID number, Rx Group number and Rx BIN number. Order your medication and take the card with you to the pharmacy where it will be used for payment. Pharmacies with the capability to bill secondary or tertiary claims electronically can submit claims directly to the PAN Foundation. If you don't have your benefit card, the pharmacy can call toll-free at 1-866-316-PANF (7263) extension 72244 for electronic billing assistance, which is available Monday through Friday, 9am to 5pm Eastern Time.

9. What about medication expenses before I got help from PAN?

During your first 12-month eligibility period, PAN will also consider for reimbursement medication expenses you incurred 90 days prior to your approval date.

10. What if I change doctors or medications?

If you change doctors or medications, please contact PAN promptly so that we can update your record and have the most up-to-date information on file.

11. Is my assistance renewable?

Any patient who meets the eligibility requirements listed in Question 1 is eligible for renewal at the end of their eligibility period if funds are available. PAN will send you a renewal application automatically at the end of your eligibility period if:

  • Your grant has remained active, and
  • You have used the minimum annual threshold, depending on the individual disease fund and
  • The specific disease fund is accepting renewal patients.

If your grant has become inactive, and you again need assistance, contact PAN Foundation for a renewal application.

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Donating to PAN

1. How can I donate to PAN Foundation?
2. Do you accept in memoriam donations in lieu of flowers?
3. How will my donation be spent?

1. How can I donate to PAN Foundation?

You can donate online, send a donation through the mail, or call the PAN office at 202-384-1474 for more information. You can set up monthly donations, donate in memory or in honor of someone you love, or designate your gift for a specific disease fund. Please see Ways to Give for more information on how you can help us support our patients.

2. Do you accept in memoriam donations in lieu of flowers?

We accept all in memoriam gifts. Gifts in lieu of flowers will be designated in memoriam to the disease fund of your choice, and a card will be sent to the family notifying them of your donation.

3. How will my donation be spent?

Over 85% of your donation will go directly to the patient. The remaining 15% pays for program management that supports our patients. This includes salaries for case managers and billing staff, fees for the pharmacy card program, supplies, and provider education and outreach efforts.

If you select a fund for your donation, your gift will be used to help patients with the disease of your choice. If you do not choose a fund, we will add your donation to our Emergency Support Fund, which backs up other funds if they temporarily run out of money and allows us to continue accepting new patients.

PAN works hard to ensure that your donations are used efficiently. Every dollar of your donation pays for program expenses. Administrative expenses are paid for through another funding source.