HeartFelt

Assistance for Patients during COVID-19

The HeartFelt Program offers financial relief to fertility patients whose cycles were canceled as a result of COVID-19 and who have initiated a new cycle. Cash-pay patients who qualify will receive medication replacement of Menopur and generic Ganirelix Acetate Injection at no additional cost. Commercially insured patients who qualify will receive a rebate of up to $250 towards their copay costs.

Eligible Medications

• Menopur (menotropins for injection) – Limit of 15 vials
• Ganirelix Acetate Injection (generic) – Limit of 5 syringes

Eligibility Requirements

• Cash-pay and commercially insured prescriptions
• Cycle was canceled due to COVID-19 between March 1 – December 31, 2020
• New cycle was initiated between June 15 – December 31, 2020
• Patient was taking Menopur during the canceled cycle

Application Instructions

1. If you were cash-pay for your medications, download the HeartFelt Medication Replacement Application. If you used commercial insurance, download the HeartFelt Co-Pay Assistance Application.

2. Complete the program application along with your physician.
3. Email the following documents to [email protected]:

– Completed program application
– Medical records showing the medications utilized prior to cycle cancellation
– Proof of purchase (i.e. itemized pharmacy receipt)
– Prescription for new cycle

4. You will be notified via email regarding your application status. If approved, cash-pay patients will be shipped replacement medication at no cost. Commercially insured patients will receive a rebate check within 45 days of approval notification.

HeartFelt Medication Replacement Application (Cash-Pay)

HeartFelt Co-Pay Assistance Application (Commercial Insurance)

For more information about this program, call 1-800-515-3784 or email [email protected].

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