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Assure for Samsca
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P.O. Box 220750
Charlotte, NC 28222
Phone
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(866)758-7069
Fax:
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Eligibility
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This program is for Healthcare Professionals Only. Patients must be uninsured. Household income must be at or below 300% federal poverty level. Patients must have a medically appropriate condition/diagnosis and must be a US citizen. |
| Who Can Apply
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Healthcare providers can call to have an application faxed or mailed or it can be downloaded. |
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Required
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Doctors must complete and sign a section of the application. Patients must complete a section of the application, sign and attach proof of income and any insurance information. Prescription and certification are required from physician and patient must be initiated or re-initiated with SAMSCA in a hospital |
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Supply
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Up to 1 month supply. |
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Ship To
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Patient's home |
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Note
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This program provides Reimbursement Services and has a Copay Assistance Program.
This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY. |
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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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| Samsca tablet |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
(Requires Acrobat Reader) 
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