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Patient Assistance Information
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7 Programs Sponsored By Astellas Pharma, Inc. (External Link)
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Astellas Patient Assistance Program for Organ Transplant
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PO Box 220708
Charlotte, NC 28222
Phone
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800-477-6472
Fax:
866-317-6235
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Eligibility
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The patient must meet income and insurance guidelines that are not disclosed. Patients with Medicare and Medicare Part D that are in the donut hole may qualify for assistance. |
| Who Can Apply
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This program will work with the patient and transplant team to complete the application process. The person who starts the process needs to have patient's diagnosis/transplant information, insurance information, health care provider information, and transplant doctor's name and phone number. |
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Required
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The doctor needs to sign the application and provide patient prescription information.The patient needs to sign the application and provide proof of income, expenses and asset information. |
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Supply
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Ship To
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Patient's home |
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Note
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This program will work with the patient and transplant team to complete the application process. The person who starts the process needs to have patient's diagnosis/transplant information, insurance information, health care provider information, and transplant doctor's name and phone number. |
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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.
| | Prograf (tacrolimus) |
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Astellas Stock Replacement Program For Adenoscan
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PO Box 220708
Charlotte, NC 28222
Phone
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800-477-6472
Fax:
866-317-6235
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Eligibility
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The patient must meet income and insurance guidelines that are not disclosed. The patient must be a US resident. |
| Who Can Apply
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The doctor, social worker, or physician office staff must call to pre-screen the patient for enrollment. |
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Required
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The doctor must fill out a section and sign the application.The patient must provide information (financial, insurance, and medical) but no signature is required. |
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Supply
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The product already used will be replaced to the facility. |
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Ship To
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Doctor's office |
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Note
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The doctor, social worker, or physician office staff must call to pre-screen the patient for enrollment. |
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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.
| | Adenoscan IV |
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Amevive Start Assistance Program
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10350 Ormsby Park Place
Suite 500
Louisville, KY 40218
Phone
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866-263-8483
Fax:
(866)420-8888
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Eligibility
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The patient must have no insurance and meet income guidelines that are not disclosed. The patient must have a diagnosis of Chronic Plaque Psoriasis.The patient must live in the US at least six months out of the year. |
| Who Can Apply
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The doctor or patient can call to request an application. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
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Up to a 30-day supply |
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Ship To
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Doctor's office |
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Note
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The doctor or patient can call to request an 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.
| | Amevive Injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Application Form | (Requires Acrobat Reader) 
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Astellas Stock Replacement Program For AmBisome
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PO Box 220708
Charlotte, NC 28222
Phone
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800-477-6472
Fax:
866-317-6235
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Eligibility
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The patient must meet income and insurance guidelines that are not disclosed. |
| Who Can Apply
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The doctor, social worker, or physician office staff must call to pre-screen the patient for enrollment. |
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Required
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The doctor must fill out a section and sign the application.The patient must provide information (financial, insurance, and medical) but no signature is required. |
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Supply
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The product that was used will be replaced for the facility. |
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Ship To
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Doctor's office. |
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Note
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Allow 10 business days for the processing and delivery of medication. |
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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.
| | Ambisome Injection |
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Astellas Stock Replacement Program For Mycamine
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PO Box 221644
Chantilly, VA 20153-1644
Phone
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800-477-6472
Fax:
703-968-2909
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Eligibility
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The patient must meet insurance and income guidelines that are not disclosed. |
| Who Can Apply
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The doctor, social worker, or physician office staff must call to pre-screen the patient for enrollment. |
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Required
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The doctor must fill out a section and sign the application.The patient must provide information (financial, insurance, and medical) but no signature is required. |
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Supply
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The product that was used will be replaced to the facility. |
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Ship To
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Doctor's office |
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Note
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The doctor, social worker, or physician office staff must call to pre-screen the patient for enrollment. |
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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.
| | Mycamine Injection |
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Astellas Patient Assistance Program for Protopic
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PO Box 221644
Chantilly, VA 20153
Phone
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(800) 477-6472
Fax:
(703) 968-2909
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Eligibility
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The patient must meet insurance and financial guidelines that are not disclosed. The patient must also be a US resident. |
| Who Can Apply
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The doctor, patient, social worker or patient advocate must call for a prescreening. The application is sent to the doctor's office. The completed application can be faxed back, but the originals must be mailed in as well. The decision is made during the phone screening. |
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Required
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The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application, and attach proof of income and any denial letters from insurance companies.
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Supply
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A 6-month supply is sent to the doctor's office. |
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Ship To
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The medication is shipped within 10 business days. |
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Note
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Every year a new application is needed. |
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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.
| | Protopic (tacrolimus) |
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Astellas Patient Assistance Program for Vaprisol
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PO Box 221644
Chantilly, VA 20153
Phone
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(800) 477-6472
Fax:
(703) 968-2909
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Eligibility
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The patient must meet insurance and financial guidelines that are not disclosed. This is a hospital replacement program, so the patient must have already received the medication. This program is only for patients who are hospital in-patients who are being treating for Euvolemic Hyponatremia. |
| Who Can Apply
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Someone from the hospital must call for an application. The application is sent to the hospital. The completed application can be faxed back, but the originals must be mailed in as well. The decision is made during the phone screening.
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Required
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The hospital contact person must fill out and sign the application. The patient must fill out a section, sign the application, and attach proof of income and any denial letters from insurance companies.
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Supply
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Ship To
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The amount requested is sent to the hospital. |
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Note
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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.
| | Vaprisol Injection |
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