rxhelp360.org
| Drug Information | ||||||||||
| Drug | AmBisome injection | |||||||||
| Generic Equivalent | amphotericin B, lipid-based | |||||||||
| Topic | Antifungals | |||||||||
| Program Contact Info / Application Submission | ||||||||||
| Program | Astellas Patient Assistance Program | |||||||||
| Company | Astellas | |||||||||
| Form | Download PDF | |||||||||
| Address | PO Box 220708 Charlotte, NC 28222-0708 | |||||||||
| Phone | 800-477-6472 | |||||||||
| Fax | 866-317-6235 | |||||||||
| Website | N/A | |||||||||
| Program Details | ||||||||||
| Details | Medication is sent to the doctor�s office. New applications are needed for each refill. | |||||||||
| Program Requirements | ||||||||||
| Information | The doctor must fill out their section and sign the application. Patients must provide financial, insurance, and medical information, but no signature is required. | |||||||||
| Details | Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income | |||||||||
| Other Requirements | Cannot assist with replacement programs | |||||||||
| Delivery of Medication | ||||||||||
| Ship Time | 10 business days | |||||||||
| Delivery Options | Can be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card | |||||||||
| Application Process | ||||||||||
| App Process | Doctors, patient, social workers or patient advocates need to call for a prescreening. Applications are sent to the doctor�s office. Completed applications must be mailed back. Decisions are made during the phone screening. Medication is shipped within 10 business days. | |||||||||
| New Applications | New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail | |||||||||
| Refills | Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can NOT apply for refills Can apply for refills via phone Can apply for refills via fax Can NOT apply for refills via mail | |||||||||
| Re-Applications | Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can NOT apply for Re-Applications Can Re-Apply via phone Can Re-Apply via fax Can NOT Re-Apply via mail | |||||||||
| Eligibility | ||||||||||
| Eligibility | Patients must meet the insurance and income guidelines that are not disclosed. This is a product replacement program. Patients must also be US residents. Patients must be applied into the program within 60 days of their last date of therapy. | |||||||||
| Other Medications | ||||||||||
| Other Medications available in this program |
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