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Patient Assistance Information

 
1 Program for DEXILANT
 
 
Takeda Pharmaceuticals 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. The patients applying for the medications Colcrys and Uloric must have an income at or below 600% of the FPL, but a nominal copay may be required (Please see the payment calculator guide for specifics on the application). Patients applying for the medications Amitiza, Dexilant, Edarbi, Edarbyclor and Rozerem must be at or below 300% of the FPL. The patient must also be a US resident. If patient has applied to Medicaid within the past year and has been denied, attach a copy of the denial letter. If patient is Medicare Part D eligible or enrolled, Section 5 or 6 must be completed.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application. The application will be faxed out. 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 and attach a prescription. The patient must fill out a section, sign the application and attach a copy of the patient’s most recent year federal tax return or financial documentation.
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.
 
DEXILANT
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Takeda Application for Amitiza, Dexilant, Edarbi, Edarbyclor and Rozerem
Download printable Form Takeda Application for Colcrys and Uloric
(Requires Acrobat Reader