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Patient Assistance Information

 
1 Program for Fycompa
 
 
Eisai Fycompa CIII Patient Assistance Program

6501 Weston Parkway
Cary, NC 27513
Phone : (855)347-2448
Fax: (888)668-8136
Eligibility
> This program is intended for uninsured patients, had denied coverage or are awaiting public assistance determination. Medicare Part D patients are not eligible for this program. Income must be at or below 300% of FPL. Patient must be a US resident.
Who Can Apply
> Call to have application mailed or complete application online. Doctor must complete application and sign. Patient must complete application sign and attach a copy of proof of income. Patient and Doctor are notified of decision.
Required
> Diagnosis/Medical Criteria must be medically necessary as determined by a Doctor.
Supply
> Amount/Supply not applicable. Refills are good for one year. New application must be completed every 12 months.
Ship To
> Patient is sent savings card to be used at pharmacy.
Note
> This program also provides copay 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.
 
Fycompa
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Eisai Fycompa CIII Patient Assistance Program
(Requires Acrobat Reader