Access To Free Medication For Fertility Preservation

Each year more than 150,000 Americans of reproductive age are diagnosed with cancer. Chemotherapy and radiation, while highly effective against cancer, may cause irreversible damage to reproductive issues. Fortunately, fertility preservation options exist to give cancer survivors the chance to build a family in the future. However, these costs are generally not covered by insurance providers. First Steps for Fertility Preservation was created to reduce this financial burden by offering select fertility medications at no cost, for approved applicants.

ELIGIBILITY REQUIREMENTS:

• US Citizen or Permanent Resident
• Female with a cancer diagnosis, but have not started treatment
• Self-pay for your medications
• Signed Oncologist and Reproductive Endocrinologist certification forms
• Income-based qualification (1040 form)

ELIGIBLE MEDICATIONS:

• Follistim AQ (2,700 IU Maximum)
• Ganirelix (5 Syringe Maximum)
• Pregnyl (1 Vial Maximum)

APPLICATION INSTRUCTIONS:

1. Download the Oncologist and Reproductive Endocrinologist certification forms provided below.
2. Ask your Oncologist and Reproductive Endocrinologist to complete and sign the certification forms.
3. Click Apply Online and upload your signed certification forms and your 1040 form. You will receive a decision letter with the status of your application within 24-48 hours.
4. If your application is approved, fax your prescription to MDR at 1-888-939-2020.
5. Call MDR at 1-800-515-3784 and provide us with the ID numbers listed on your approval letter. We will ship the medication at no cost.

Download physician certification forms below.

Reproductive Endocrinologist Certification Form

ENGLISH

Download the Reproductive Endocrinologist Certification Form to complete your First Steps application, and see if you qualify to receive select fertility medication at no cost.

Formulario de Certificación del Endocrinólogo Reproductivo

ESPAÑOL

Descarga el formulario de certificación del endocrinólogo para completar su aplicación de Primeros Pasos, y confirma si es elegible para recibir unos medicamentos de fertilidad sin costo.

Oncologist Referral and Certification Form

ENGLISH

Download the Oncologist Referral and Certification Form to complete your First Steps application, and see if you qualify to receive select fertility medication at no cost.

Formulario de Certificación y Oncólogo Referido

ESPAÑOL

Descarga el formulario de certificación y oncólogo referido para completar su aplicación de Primeros Pasos, y confirma si es elegible para recibir unos medicamentos de fertilidad sin costo.