The Leukemia & Lymphoma Society is pleased to announce technology enhancements for the Co-Pay Assistance Program!
Please take advantage of the following educational webinars for an overview of the technology enhancements.
- Development of a dedicated portal to better service pharmacies
- Integration of electronic signature for online applications
- Integration of import capabilities allowing users to upload documents directly or auto import faxed documents
- Implementation of a unique barcode recognition system for faxed documents
- Matching barcode system will attach documents to faxed/uploaded applications
- Provider Notification of Patient Approval
Welcome to The Leukemia & Lymphoma Society Co-Pay Assistance Program Patient Online Application.
The Co-Pay Assistance program provides you with financial assistance for health insurance payments and with blood cancer treatment co-pay obligations. 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
- your diagnosis name
- 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
After you complete the online information, you'll have the option to either print out the application in its entirety. Or, you can submit the application to Co-Pay to be mailed to the patient for his or her signature.
Please note that only one application may be completed per patient.
After you complete the application, identify yourself as either the patient or someone submitting the application on behalf of the patient. An additional area is available to type in any special comments relevant to the application or special circumstances.
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, you can request that the application be mailed to the patient if he or she doesn't have printing capabilities. The patient can then sign the application and return it by mail using the preposted envelope provided by LLS or fax the application to the Co-Pay Program, along with the required documentation.
The completed application is uploaded to the Co-Pay Database. The upload will occur 24 hours after your submit the application. The Co-Pay team will fax the doctor's confirmation form to 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:
- a signed patient application
- household financial information
- a doctor's 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