Welcome to The Leukemia & Lymphoma Society Co-Pay Assistance Program Patient Online Application.
Co-Pay applications can be submitted online through this secure web-based process or by calling the Co-Pay Center at (877) 557-2672.
We've created this site as a convenient alternative for you to apply to the LLS Co-Pay Assistance Program. The online application process should take approximately seven minutes to complete.
You'll need the following information and documents before you begin the online application:
- Your Social Security number and date of birth
- the name of your diagnosis
- the name of your insurance companies plus group, policy and ID number, as well as Medicare/Medicaid
- the name of your pharmacy and its phone and fax numbers
- the name of your physician and his or her phone and fax numbers
- financial documents such as your most recent tax returns, 1099s, Social Security, benefit statements or W-2s
Before you begin the application process, please read the following information.
If this is your first time visiting the Co-Pay Assistance Online Patient Portal, you'll need to register before you can start the online application process.
You must have a valid email address to register. Once you submit your registration, you'll receive an email (typically within five minutes) directing you to a website to create your password. You can then begin entering your application information.
Entering and Submitting the Application
Please note that only one application may be completed per patient. After you complete the application, you must identify yourself as either the patient or someone submitting the application on behalf of the patient. A comments section is available to include any additional information or special circumstances relevant to the application.
Option 1: Print the application, sign it and mail or fax it back to the Co-Pay Program, along with the required documentation.
Option 2: If you are a healthcare provider or caregiver, or if the patient does not have printing capabilities, you can request that the application be mailed to the patient. The patient can then sign the application and return it to the Co-Pay Program by mail (pre-posted envelope is provided), or by fax, along with the required documentation.
The online portion of the completed application is uploaded to the Co-Pay Database. It takes 24 hours to upload. The Co-Pay staff then faxes the Physician Form to the doctor. Please make sure that you provide the doctor's fax number.
Within approximately five minutes after submitting the application on the website, a confirmation of receipt will be sent to the email address you provided during registration.
Submitting the application online doesn't guarantee acceptance in the program. All applications must be completed in their entirety before they can be reviewed and must include:
- signed patient application
- household financial information
- physician form
- a copy of the patient's insurance card
The Co-Pay team will review all your documents and inform you via mail of your approval status.
Support for this program is based on the availability of funds by disease diagnosis.
For More Information
For information or questions regarding the Co-Pay Assistance program application contact:
1-877-LLS-COPAY or 1-877-557-2672
The Leukemia & Lymphoma Society
Co-Pay Assistance Program
P.O. Box 12268
Newport News, VA 23612
Fax: (877)-COPAY-FAX or (877) 267-2932