Welcome to The Leukemia & Lymphoma Society Co-Pay Assistance Program Patient Online Application.

The Co-Pay Assistance program provides patients 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 have 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 7 minutes to complete.

Please gather the following required information and documents before you begin the online application.
• Patient' Social Security Number & Date of Birth
• Diagnosis Name
• Name of Insurance Companies including group, policy and ID number, as well as Medicare/Medicaid
• Name of Pharmacy, Phone & Fax Numbers
• Name of Physician, Phone & Fax Numbers
• Financial Documents, such as the patient's most recent Tax Returns, 1099s, S.S., Benefit Statements or W-2s

Before beginning the application please review the following information.

Registration Process
If this is your first time visiting the Co-Pay Assistance Online Patient Portal you will need to register before you can start the online application process. 

A valid email address is required to complete the registration process. Once the registration is submitted, you will receive an email (typically within 5 minutes) directing you to a website to create your password. You can then begin entering your application information.

Entering & Submitting the Application
Please note that only one application may be completed per patient.

Once all the information is completely entered the person submitting the application can identify him or herself as either the patient or someone submitting the application on behalf of the patient. There is also an additional area to type in any special comments relevant to the application or the patient's special circumstances.
 
Once submitted, there is an option to either download the application in its entirety or request the application be mailed directly to the patient which will be done within 24 hours.

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 Request the application be mailed to the patient, for those patients without printing capabilities. The patient can then sign the application and return it by mail using the pre-posted envelope provided by LLS or fax the application to the Co-Pay Program, along with the required documentation.

After choosing one of these options, the application will be uploaded to the Co-Pay Database. The upload will occur 24 hours after the application is submitted. The Co-Pay team will also fax the physician's confirmation form to the physician's office if the physician's fax number has been provided by the applicant.

Email Confirmation
Within approximately 5 minutes after submitting the application, a confirmation of receipt will be sent to the email address provided at the point of registration.

Review of the Application
Submitting the application online does not guarantee acceptance in the program. All applications must be completed in its entirety before it can be reviewed. A complete Co-Pay application includes the following in order for a determination to be made: a signed patient application, household financial information, physician's form, and 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.

Start New Patient Application

To go back to the LLS Co-Pay Assistance website

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
copay@lls.org
www.lls.org/copay