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Patient Assistance Information

Takeda Patient Assistance Program

P.O. Box 5727
Louisville, KY 40255
Phone : 800-830-9159
Fax: 800-497-0928
> The patient must have no prescription coverage for any medications and be ineligible for state or federal program but may have Medicare Part D. The patients must have an income at or below 400% of the Federal Poverty Level and be a US resident.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application. The application will be faxed, mailed or can be downloaded. The completed application must be faxed or mailed from the doctor's office. Both the patient and doctor are notified in writing of acceptance or denial.
> The doctor must fill out a section, sign the application, attach a prescription and include DEA or state license. The patient must fill out a section, sign the application and attach a copy of proof of income.
> A 90 day supply is mailed. Once a year a new application with financial documentation is needed.
Ship To
> The medication is sent to either the patient's home or Physician's office.
> With the patient's permission, anyone concerned can call for an application.
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.
Amitiza Capsules
Brintellix tablet
Kazano tablet
Nesina tablet
Oseni tablet
Prevacid SoluTab tablet; delayed release
Rozerem Tablets
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader