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Patient Assistance Information

 
 
 
ACT Program

ACT Program
PO Box 18979
Louisville, KY 40261
Phone : 866-363-6379
Fax: 866-363-6389
Eligibility
> This program provides brand name medications at no or low cost to patients that are uninsured or underinsured. Medicare Part D recipients are eligible. Patients must be at or below 500% of the federal poverty level. Patients must be a US resident and be treated by a US licensed healthcare provider.
Who Can Apply
> Anyone interested can call or download an application and it will be faxed, emailed or mailed to them.
Required
> Doctors must complete, sign and attach a prescription to the application. Patients must complete and sign and the completed application can be sent by fax or mail.
Supply
> Up to 30 day supply
Ship To
> Doctor's office or patient's home
Note
> Patients in need who appear not to qualify should still call.
 
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.
 
Noxafil tablet; delayed release
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader