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Assure for Rexulti
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Otsuka
PO Box 220684
Charlotte, NC 28222
Phone
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(844)687-8526
Fax:
(844)687-8528
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Eligibility
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This program provides brand name medications at no or low cost to patients that have a household income that is at or below 300% of the federal poverty level. Insurance status requirements and residency requirements have not been specified. Patients must have a medically necessary diagnosis or condition. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed, mailed or one can be downloaded. |
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Required
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Doctors must complete a section of the application. Patients must complete a section, sign and attach required documents. A new application is required yearly. |
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Supply
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Up to 1 month supply |
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Ship To
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Not specified |
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Note
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This program also provides copay assistance. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Rexulti tablet |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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