Menu
Apply
Patients & Family

Patients & FamilyYou take care of yourself. We’ll take care of the financial strain.

At Patient Advocate Foundation Co-Pay Relief Program, we put patient and family peace of mind above all else. We provide direct payment for co-pays, co-insurance, and deductibles for patients who need financial assistance.

Apply

What can we help with?

PAF’s Co-Pay Relief (CPR) program provides direct financial assistance to qualified patients with co-payments, co- insurance or cost-sharing associated with prescription drugs through funds dedicated to specific disease states. In some instances, assistance with insurance premiums and/or ancillary services associated with the disease also may be available.


Required Information to Complete an Application for Assistance:

Patient Demographic Information

  • First & Last Name
  • Address & Phone Number
  • Gender, Ethnicity & Marital Status
  • Veteran Status, Employment Status, Date of Birth
  • Social Security Number or Alien Number
  • Financial Information
  • Number in Household

Annual Household Income

  • Do you file a Tax Return for the most current year?
  • Has your Annual Income changed significantly from last year?

Authorized Person

  • Is anyone else authorized to speak with CPR on the Patient’s behalf?
  • If yes, the following fields are required: First Name, Last Name, Relationship, Special Authorization, Phone
    Number

Insurance Information

  • Primary Insurance Carrier Insurance & Plan Type Policy ID & Group Number Telephone Number
  • Subscriber’s Name and Date of Birth
  • Co-Pay or Coinsurance for medical services
  • Co-Pay or Coinsurance for pharmacy benefits
  • Do you have Medicare Part D?
  • Does the patient have a Medicare Supplement? Do you have Secondary Insurance?
  • Is Insurance coverage continuation under COBRA in effect?
  • Does this plan cover prescription drugs at the pharmacy and provider office?

Treating Physician Information

  • Physician Name Facility Name Physical Address
  • Phone and Fax Number
  • Office Contact Name and Email Address, if known

Medical Diagnosis

  • Primary Diagnosis
  • Date of Diagnosis

Prescribed Medication

  • Medication Name(s) seeking assistance with

Submitting Documents: What are the options?

CPR accepts documents via Virtual Pharmacy Card, electronic upload, fax or by mail

For applications submitted through our website, supporting documents may be uploaded electronically

  • Please allow 24 to 48 hours for uploaded documents to reflect on the online portal.

Applications and supporting documents may be faxed

  • Please use the unique bar-coded fax coversheet when faxing information to CPR.
  • Please note that each application submission has a unique bar code and the applications are not interchangeable.

Mail application and supporting documents

Program Contact Information:
Web Portals: www.copays.org
Phone Number 866-512-3861 Fax Number: 757-952-0119
Address: Patient Advocate Foundation Co-Pay Relief Program; 421 Butler Farm Road, Hampton, VA 23666


I’m Approved, What Now?

  • Patients approved for assistance are required to have their verified diagnosis and treatment plan along with supporting documentation completed and returned within 30 days of approval to ensure continuation of the award.
  • Your treating physician can upload the diagnosis and treatment plan document(s) to the online portal or fax to us using the unique bar-coded fax cover sheet.
  • Approved patients who do not submit a completed physician form verifying the reported diagnosis within 30 days from approval will forfeit their award and will not be eligible to reapply to the program until 12 months from the original date of approval.
  • If you are requested to provide documentation of your reported income, please submit your documentation to the program within 30 days of approval to ensure continuation of the award.
  • If the requested income documents are not received within 30 days from the date the application was initiated, the award will be forfeited, and you will not be eligible to reapply to the program until 12 months from the original date of the application.
  • Income documents can be uploaded to the online portal or faxed to us using the unique bar-coded fax cover sheet.
  • Once approved, begin using your award immediately! Please submit your claims via Virtual Pharmacy Card, uploading them to the online portal or faxed to us using the unique bar-coded fax cover sheet.
How do I qualify?
  • Must be currently insured and have coverage for medication seeking financial assistance
  • Have a confirmed diagnosis and treatment plan
  • Must reside and receive treatment in the United States
  • Income must fall at or below 300% or 400% of the Federal Poverty Guideline (FPG) with consideration for the Cost of Living Index (COLI) and number in the household
  • Applications can also be completed by contacting us toll free at 866-512-3861, to be connected to a CPR Specialist

Welcome to the Co-Pay Relief program!

Patient Resource Center – National Finance Resources Directories

Apply