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Acthar Support & Access Program (A.S.A.P)
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Phone
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888-435-2284
Fax:
877-937-2284
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Eligibility
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The patient must be uninsured or underinsured. Income requirements for this program have not been disclosed. The patient must be a US citizen being treated by a US doctor. |
Who Can Apply
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The doctor or doctor's office must call or download the application. |
Required
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The doctor must fill out a section of the application and sign. The patient must fill out a section, sign the application, and attach insurance information. The application can then be faxed from the doctor's office. |
Supply
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Not specified. |
Ship To
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Patient's home, doctor's office, hospital or pharmacy |
Note
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This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY.
This program also provides copay assistance.
Contact program for Spanish application. |
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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. |
Acthar Gel injection |
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Printable Application Forms Applications that patients can fill out and bring to their doctor. |
Download printable Form |
Download printable Form |
(Requires Acrobat Reader)
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