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Patient Assistance Information

 
 
 
Assure for Samsca

P.O. Box 220750
Charlotte, NC 28222
Phone : (866)758-7069
Fax:
Eligibility
> 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
> Healthcare providers can call to have an application faxed or mailed or it can be downloaded.
Required
> 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
Supply
> Up to 1 month supply.
Ship To
> Patient's home
Note
> 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.
 
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.
 
Samsca tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader