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Patient Assistance Information

 
 
 
Acthar Support & Access Program (A.S.A.P)


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Phone : 888-435-2284
Fax: 877-937-2284
Eligibility
> 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
> The doctor or doctor's office must call or download the application.
Required
> 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.
Supply
> Not specified.
Ship To
> Patient's home, doctor's office, hospital or pharmacy
Note
> 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.
 
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.
 
Acthar Gel injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader