Boy with doctor in exam room

Boy with doctor in exam room

Enrollment

To receive help from EveryDay Support From Day One, you must complete the enrollment form, and your patient or their legal guardian must provide consent.

There are 2 steps to enroll:

Fill out pages 1-2 of the enrollment form as completely as possible.

You can download the form by clicking the button below. Once the form is completed, it can be printed and signed by the patient. You can then submit it via fax to 855-332-9663 or secure email to [email protected].
Download the English enrollment form Download the Spanish enrollment form
Obtain patient consent.

Your patient or their legal guardian may provide consent in 1 of 2 ways:

Reviewing and signing the Patient Authorization section (pages 3-4) of the enrollment form in the office.

Providing consent electronically by completing the enrollment form online.

Complete the English enrollment form online Complete the Spanish enrollment form online

Danielle, support team member

For questions or assistance, call EveryDay Support From Day One at 855-DAY1-BIO/ 855-329-1246 .

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Terms & Conditions

Day One Biopharmaceuticals’ Copay Program (the “Program”) is available only for patients with commercial insurance with a valid prescription residing in the United States and Puerto Rico, and is void where prohibited by law. The patient or their guardian must be 18 years of age or older. Patients using Medicare (including Medicare Part D), Medicaid, Medigap, Veterans Affairs, Department of Defense, TRICARE, Children’s Health Insurance Program, or any other federal or state government program to pay in whole or in part for their treatment are not eligible to participate. Patient must have commercial health insurance that covers medication costs, but not the full cost to the patient. Patient may not seek reimbursement for the value received from this program or cost of the prescription from other parties, including any health insurance program or plan (whether private or public), flexible spending account, or health care savings account. The Program is not transferable or substitutable and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer. The Program offer may not be sold, purchased, traded, or counterfeited. This Program is not health insurance.

The value of this program is exclusively for the benefit of enrolled patients and is intended to be credited toward patient out-of-pocket obligations, including applicable co-payments, co-insurance, and deductibles for their medicine, up to an established maximum amount per calendar year. It does not assist with the cost of other medications or office visit fees. After reaching the maximum Program benefit, the patient will be responsible for any remaining out-of-pocket costs for the medication incurred during that calendar year. The maximum Program benefit is provided annually, and it expires at the end of the calendar year and will reset every January 1st. Eligible patients will be automatically re-enrolled in the Program on an annual basis if the patient continues to meet all eligibility requirements set forth by the Program. Program participants are required to immediately inform EveryDay Support From Day One of insurance changes or if the patient is no longer eligible to receive Program benefits.

The Program may modify the benefit amount, unilaterally determined by Day One Biopharmaceuticals in its sole discretion, to satisfy the out-of-pocket cost sharing requirement for any patient whose insurance plan or insurance plan agent (including, but not limited to, a Pharmacy Benefit Manager (PBM) requires enrollment in the Program as a condition of the insurance plan or PBM waiving some or all of an otherwise applicable patient out-of-pocket cost sharing amount. These programs are often referred to as co-pay maximizer programs. If you believe your insurance plan may have such limitations, please contact EveryDay Support From Day One at 855-DAY1-BIO/855-329-1246.

Day One Biopharmaceuticals reserves the right to rescind, revoke or amend this offer, eligibility, and terms of use at any time without notice.