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Acthar Support & Access Program (A.S.A.P)
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Phone
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888-435-2284
Fax:
877-937-2284
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Eligibility
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The patient must be uninsured or underinsured. Income requirements for this program have not been disclosed. The patient must be a US citizen being treated by a US doctor. |
| Who Can Apply
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The doctor or doctor's office must call or download the application. |
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Required
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The doctor must fill out a section of the application and sign. The patient must fill out a section, sign the application, and attach insurance information. The application can then be faxed from the doctor's office. |
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Supply
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Not specified. |
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Ship To
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Patient's home, doctor's office, hospital or pharmacy |
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Note
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This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY.
This program also provides copay assistance.
Contact program for Spanish application. |
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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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| Acthar Gel injection |
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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 |
| Download printable Form |
(Requires Acrobat Reader) 
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