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Eisai Fycompa CIII Patient Assistance Program
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6501 Weston Parkway
Cary, NC 27513
Phone
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(855)347-2448
Fax:
(888)668-8136
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Eligibility
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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
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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. |
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Required
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Diagnosis/Medical Criteria must be medically necessary as determined by a Doctor. |
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Supply
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Amount/Supply not applicable. Refills are good for one year. New application must be completed every 12 months. |
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Ship To
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Patient is sent savings card to be used at pharmacy. |
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Note
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This program also provides copay assistance. |
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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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| Fycompa |
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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 Eisai Fycompa CIII Patient Assistance Program |
(Requires Acrobat Reader) 
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