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Patient Assistance Information

 
2 Programs for Benicar HCT Tablets
 
 
Daiichi Sankyo Open Care Program

PO Box 8409
Somerville, NJ 08876
Phone : 866-268-7327 Ext 1
Fax: Not Applicable
Eligibility
> This program is intended for patients that are uninsured. Medicare Part D patients are not eligible for this program. Patient's income must be at or below 200% FPL. Must be citizen or legal resident.
Who Can Apply
> The physician's office must call for application, which will be faxed. Application can be returned via fax or mail. Patient will be notified of denial in writing.
Required
> Doctor must complete section, sign, attach required documents. Patient must complete section, sign, attach a copy of proof of income.
Supply
> Up to 90 day supply. Patient or Doctor must contact company for refills. Refill limit not specified. New application and documentation is required yearly.
Ship To
> Medication is sent to Doctor's office within 2 weeks.
Note
> No online application available.
 
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.
 
Benicar HCT Tablets
 
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US.
Who Can Apply
> Patients or healthcare providers can complete the application online or by phone.
Required
> Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
 
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.
 
Benicar HCT Tablets
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader