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Patient Assistance Information

 
2 Programs Sponsored By Takeda Pharmaceuticals America, Inc (External Link)
 
 
Takeda Patient Assistance Program

P.O. Box 5727
Louisville, KY 40255
Phone : 800-830-9159
Fax: 800-497-0928
Eligibility
> The patient must have no prescription coverage for any medications and be ineligible for state or federal program but may have Medicare Part D. The patients must have an income at or below 400% of the Federal Poverty Level and be a US resident.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application. The application will be faxed, mailed or can be downloaded. The completed application must be faxed or mailed from the doctor's office. Both the patient and doctor are notified in writing of acceptance or denial.
Required
> The doctor must fill out a section, sign the application, attach a prescription and include DEA or state license. The patient must fill out a section, sign the application and attach a copy of proof of income.
Supply
> A 90 day supply is mailed. Once a year a new application with financial documentation is needed.
Ship To
> The medication is sent to either the patient's home or Physician's office.
Note
> With the patient's permission, anyone concerned can call for an application.
 
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.
 
Amitiza Capsules
Brintellix tablet
Colcrys
Contrave
DEXILANT
Kazano tablet
Nesina tablet
Oseni tablet
Prevacid SoluTab tablet; delayed release
Rozerem Tablets
ULORIC
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Entyvio Connect


,
Phone : 855-368-9846
Fax: 877-488-6814
Eligibility
> Insurance status and income will be considered on a case by case basis. Patients must have an FDA-approved diagnosis and be a US resident.
Who Can Apply
> Patients must call for a pre-screening and then an application will be mailed.
Required
> Doctors must complete a section, sign, and attach a brand name prescription. Patients must complete a section, sign, and attach proof of income.
Supply
> Not specified
Ship To
> Doctor's office or infusion site
Note
> This program also provides co-pay and reimbursement 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.
 
Entyvio
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader