Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
 
 
Assure for Rexulti

Otsuka
PO Box 220684
Charlotte, NC 28222
Phone : (844)687-8526
Fax: (844)687-8528
Eligibility
> This program provides brand name medications at no or low cost to patients that have a household income that is at or below 300% of the federal poverty level. Insurance status requirements and residency requirements have not been specified. Patients must have a medically necessary diagnosis or condition.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed, mailed or one can be downloaded.
Required
> Doctors must complete a section of the application. Patients must complete a section, sign and attach required documents. A new application is required yearly.
Supply
> Up to 1 month supply
Ship To
> Not specified
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.
 
Rexulti tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader