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Assure for Abilify Maintena
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Otsuka
PO Box 220684
Charlotte, NC 28222
Phone
:
855-999-2627
Fax:
855-876-2627
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Eligibility
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This program is for Healthcare Professionals Only.
Patients must be uninsured or underinsured with no prescription coverage. Patients must be at or below 300% of the federal poverty level. Diagnosis and residency requirements have not been disclosed. |
| Who Can Apply
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Doctors or the doctor's office must call for an application to be faxed or it can be downloaded. |
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Required
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Patients must inform their doctor that they are in need. Doctors must enroll in the program, complete the application form and obtain the patients consent. |
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Supply
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Up to 1 month supply |
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Ship To
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Doctor's office |
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Note
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Resources for HEALTHCARE PROFESSIONALS ONLY. |
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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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| Abilify Maintena injection; extended release |
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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 |
(Requires Acrobat Reader) 
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Assure for Samsca
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P.O. Box 220750
Charlotte, NC 28222
Phone
:
(866)758-7069
Fax:
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Eligibility
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This program is for Healthcare Professionals Only. Patients must be uninsured. Household income must be at or below 300% federal poverty level. Patients must have a medically appropriate condition/diagnosis and must be a US citizen. |
| Who Can Apply
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Healthcare providers can call to have an application faxed or mailed or it can be downloaded. |
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Required
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Doctors must complete and sign a section of the application. Patients must complete a section of the application, sign and attach proof of income and any insurance information. Prescription and certification are required from physician and patient must be initiated or re-initiated with SAMSCA in a hospital |
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Supply
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Up to 1 month 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 provides Reimbursement Services and has a Copay Assistance Program.
This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY. |
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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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| Samsca tablet |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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Assure for Rexulti
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Otsuka
PO Box 220684
Charlotte, NC 28222
Phone
:
(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.
|
| Rexulti tablet |
| |
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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