Patient Assistance Program

Patient Assistance Program Terms & Conditions

Income Eligibility

To be eligible for the ValorumPRO Patient Assistance Program, patients must meet the applicable financial and insurance eligibility requirements below:

  • ARMLUPEG: Household income at or below 500% of the Federal Poverty Level and uninsured or functionally uninsured.

Program Eligibility Requirements

To participate in the ValorumPRO Patient Assistance Program:

  • The patient must be a resident of the United States and physically reside in one of the 50 U.S. states, Washington, D.C., Puerto Rico, or the U.S. Virgin Islands.
  • Patients whose prescription drug coverage is provided through certain Veterans Affairs or military-related healthcare programs, including TRICARE For Life and CHAMPVA, are not eligible.
  • Patients who may be eligible for Medicaid must have received a Medicaid denial within the previous twelve (12) months.
  • Patients enrolled in Medicare Part A, Part B, or Part D may be eligible if they meet the Program’s financial hardship criteria and are otherwise unable to afford the prescribed therapy.
  • Eligibility is subject to verification and final determination by the ValorumPRO Patient Assistance Program.

Patient or Legally Authorized Representative Attestation

By applying to the Program, the patient or the patient’s legally authorized representative certifies and agrees that:

  • The individual completing the application is the patient or is legally authorized to act on the patient’s behalf.
  • The patient is a United States resident and physically resides in one of the 50 U.S. states, Washington, D.C., Puerto Rico, or the U.S. Virgin Islands.
  • The prescribed therapy is unaffordable to the patient based on the patient’s current financial circumstances.
  • No other available source of financial assistance is sufficient to provide access to the prescribed therapy.
  • The patient or legally authorized representative will provide supporting documentation, including proof of income and insurance information, if requested by the Program for purposes of eligibility verification.
  • All information provided in connection with the application is complete and accurate to the best of the applicant’s knowledge.

Healthcare Provider Attestation

By prescribing or participating in the Program, the healthcare provider attests and agrees that:

  • Product provided through the ValorumPRO Patient Assistance Program will be provided to the eligible patient at no cost.
  • Neither the product nor any portion of its cost will be billed to, submitted for reimbursement from, or otherwise charged to any third-party payer, including Medicare, Medicaid, TRICARE, other federal or state healthcare programs, commercial insurance, or the patient.
  • The decision to prescribe the product was made based solely on the healthcare provider’s independent clinical judgment and was not contingent upon, influenced by, or conditioned on the availability of assistance through the ValorumPRO Patient Assistance Program.
  • The healthcare provider will comply with all applicable federal and state laws, regulations, and Program requirements associated with receipt and administration of product provided through the Program.

Documentation Requirements

The Program may request documentation to verify eligibility. Requested documentation may include, but is not limited to:

  • A copy of the patient’s most recent IRS Form 1040, 1040-SR, or other acceptable documentation of household income.
  • A copy of the patient’s current insurance card, if applicable.
  • Documentation of Medicaid denial, when required.
  • Other documentation reasonably necessary to verify financial hardship, insurance status, residency, or Program eligibility.

Failure to provide requested documentation may result in delayed approval, denial of enrollment, or termination from the Program.

Eligibility Period and Re-Enrollment

Patients who are approved for the ValorumPRO Patient Assistance Program will generally remain eligible for up to twelve (12) months from the date of approval, subject to continued satisfaction of Program requirements.

Patients must reapply annually and may be required to submit updated financial, insurance, residency, and other eligibility documentation.

Eligibility may be reassessed at any time if the patient’s insurance coverage, financial circumstances, residency, or other relevant eligibility information changes.

Changes in Eligibility

Patients and Providers are responsible for promptly notifying ValorumPRO of any change in insurance coverage, income, residency, household status, or other circumstances that may affect eligibility for the Patient Assistance Program.

ValorumPRO may verify or reverify eligibility at any time. Assistance may be modified, suspended, or discontinued if a patient no longer meets program eligibility requirements, fails to provide requested documentation, or provides information that is incomplete, inaccurate, or misleading.

Continued participation in the program is not guaranteed and is subject to ongoing satisfaction of all applicable eligibility requirements and program terms.

Additional Program Terms

Functionally Uninsured = two part test (i) they have insurance, and insurance will not cover the product, and (ii) they meet our indigent criteria.

ValorumPRO reserves the right to verify information submitted in connection with an application, request additional documentation, modify eligibility criteria, suspend or terminate participation, or discontinue the Program at any time, subject to applicable law.

Participation in the Program does not guarantee continued product availability or eligibility for future assistance.

Program assistance is not contingent on any past, present, or future purchase, prescription, recommendation, or use of any Valorum product.

Questions about program eligibility? Contact ValorumPRO