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ACT Program
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ACT Program
PO Box 18979
Louisville, KY 40261
Phone
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866-363-6379
Fax:
866-363-6389
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Eligibility
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This program provides brand name medications at no or low cost to patients that are uninsured or underinsured. Medicare Part D recipients are eligible. Patients must be at or below 500% of the federal poverty level. Patients must be a US resident and be treated by a US licensed healthcare provider. |
| Who Can Apply
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Anyone interested can call or download an application and it will be faxed, emailed or mailed to them. |
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Required
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Doctors must complete, sign and attach a prescription to the application. Patients must complete and sign and the completed application can be sent by fax or mail. |
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Supply
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Up to 30 day supply |
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Ship To
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Doctor's office or patient's home |
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Note
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Patients in need who appear not to qualify should still call. |
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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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| Noxafil tablet; delayed 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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Entereg Access Support and Education (E.A.S.E.)
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,
Phone
:
877-282-4786
Ext opt4
Fax:
800-278-1365
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Eligibility
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This program is for healthcare professionals only. Insurance, income and residency requirements have not been disclosed for this program. |
| Who Can Apply
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The doctor or the doctor's office must call or download an application. |
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Required
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The patient must inform the doctor that he or she is in need. The hospital contact must complete, sign and fax the form. |
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Supply
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Varies |
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Ship To
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Hospital |
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Note
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Resources for HEALTHCARE PROFESSIONALS ONLY.
Entereg is available only to hospitals that enroll in the E.A.S.E. Program and is available only for short-term (15 doses) use in hospitalized patients. |
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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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| Entereg capsule |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| Download printable Form |
| (Requires Acrobat Reader)
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