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Axcan ASSIST Program
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PO Box 52065
Phoenix, AZ 85072-9152
Phone
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866-292-2679
Fax:
Not Applicable
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below 200% of the Federal Poverty Level. The patient must also be a US resident under the age of 65. |
| Who Can Apply
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Anyone can call to request an enrollment kit to be sent out. |
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Required
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The doctor needs to provide a prescription to the patient. The patient must fill out a section and sign the application. |
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Supply
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The patient is sent a pharmacy card to be used once a month. |
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Ship To
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Patient's home |
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Note
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There is a $2 co-pay at the pharmacy. |
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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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| Ultrase MT 20 Powder |
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