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Takeda Patient Assistance Program
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P.O. Box 5727
Louisville, KY 40255
Phone
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800-830-9159
Fax:
800-497-0928
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Eligibility
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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
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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. |
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Required
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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. |
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Supply
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A 90 day supply is mailed. Once a year a new application with financial documentation is needed. |
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Ship To
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The medication is sent to either the patient's home or Physician's office. |
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Note
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With the patient's permission, anyone concerned can call for 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.
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| Amitiza Capsules |
| Brintellix tablet |
| Colcrys |
| Contrave |
| DEXILANT |
| Kazano tablet |
| Nesina tablet |
| Oseni tablet |
| Prevacid SoluTab tablet; delayed release |
| Rozerem Tablets |
| ULORIC |
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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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Entyvio Connect
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,
Phone
:
855-368-9846
Fax:
877-488-6814
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Eligibility
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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
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Patients must call for a pre-screening and then an application will be mailed. |
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Required
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Doctors must complete a section, sign, and attach a brand name prescription. Patients must complete a section, sign, and attach proof of income. |
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Supply
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Not specified |
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Ship To
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Doctor's office or infusion site |
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Note
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This program also provides co-pay and reimbursement 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.
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| Entyvio |
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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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