Aciphex Patient Assistance Program
Monday, August 18th, 2008| Pharmaceutical Company | Aciphex Patient Assistance Program (Eisai, Inc.) |
| Program Address | Aciphex Patient Assistance Program Charlotte NC 28222-0458 |
| Toll Free Phone Number | 800-523-5870 |
| Fax Number | 800-526-6651 |
| Guidelines and Notes | Program is a joint venture between Eisai and Janssen Pharmaceuticals. US residents with no prescription coverage may qualify to get Aciphex free. They can’t have Medicaid, private insurance for prescriptions or an HMO with drug coverage, and their income must fall within the programs guidelines. Call between 9-5 Eastern Time weekdays. |
| Initiating Enrollment | Call for application. |
| Health Provider’s Role | Physician completes physician information, shipping information and prescription information and signs form. Form can be faxed. Indicate if it is a new application or a re-application. |
| Patient’s Role | Complete form including patient informationk health insurance information, and financial application and attach a copy of most recent federal tax return (or other applicable proof of income). Sign form. |
| How Dispensed | Sent to physician. |
| Amount Dispensed | 30 day supply of 20 mg tablets. |
| Refills | Not Specified |
| Limit | Indefinitely |