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Patient Assistance Information

 
3 Programs Sponsored By Otsuka (External Link)
 
 
Assure for Abilify Maintena

Otsuka
PO Box 220684
Charlotte, NC 28222
Phone : 855-999-2627
Fax: 855-876-2627
Eligibility
> 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
> Doctors or the doctor's office must call for an application to be faxed or it can be downloaded.
Required
> 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.
Supply
> Up to 1 month supply
Ship To
> Doctor's office
Note
> Resources for HEALTHCARE PROFESSIONALS ONLY.
 
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.
 
Abilify Maintena injection; extended release
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Assure for Samsca

P.O. Box 220750
Charlotte, NC 28222
Phone : (866)758-7069
Fax:
Eligibility
> 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
> Healthcare providers can call to have an application faxed or mailed or it can be downloaded.
Required
> 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
Supply
> Up to 1 month supply.
Ship To
> Patient's home
Note
> 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.
 
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.
 
Samsca tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Assure for Rexulti

Otsuka
PO Box 220684
Charlotte, NC 28222
Phone : (844)687-8526
Fax: (844)687-8528
Eligibility
> 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
> Patients or healthcare providers can call to have an application faxed, mailed or one can be downloaded.
Required
> Doctors must complete a section of the application. Patients must complete a section, sign and attach required documents. A new application is required yearly.
Supply
> Up to 1 month supply
Ship To
> Not specified
Note
> This program also provides copay assistance.
 
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