Cancer Patients Save up to 100% on Select Medication

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. The ReUnite Oncofertility Program was created to reduce this financial burden by offering up to a 100% discount on select fertility medications based on financial need.

ELIGIBLE MEDICATIONS:

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

ELIGIBILITY REQUIREMENTS:

• Self-pay patient (no fertility drug benefits)
• Female patients requiring cancer treatments affecting their fertility
• No prior chemotherapy
• Completed ​ReUnite Oncofertility Application
• Current proof of income (1040 tax document)

APPLICATION INSTRUCTIONS:

1. Download the ReUnite Oncofertility Application
2. Complete the patient form (Page 1) and ask your Oncologist to complete and sign the Oncologist form (Page 2).
3. Submit your completed application to Reunite Rx:
– Fax to (214) 614-4332
– Email to info@reuniterx.com
4. When​ your application is approved, contact MDR at 1-800-515-3784 and provide us with the ID numbers listed on your approval letter. We will apply the discount to your medication order.