rxhelp360.org
| Drug Information | ||||||||||||||||
| Drug | Benicar HCT | |||||||||||||||
| Class | angiotension II antagonist + diuretic | |||||||||||||||
| Topic | BloodPressure | |||||||||||||||
| Program Contact Info / Application Submission | ||||||||||||||||
| Program | DaiichiSankyo Pharma Open Care Program | |||||||||||||||
| Company | Sankyo | |||||||||||||||
| Form | Download PDF | |||||||||||||||
| Program Requirements | ||||||||||||||||
| Details | Insurance card NOT required Drivers license NOT required Proof of Income NOT required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero incomeNOT required as proof of income Most recent check/check stub copy required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income | |||||||||||||||
| Delivery of Medication | ||||||||||||||||
| Delivery Options | Can NOT be delivered directly to the patient Can be delivered directly to the doctor | |||||||||||||||
| Application Process | ||||||||||||||||
| New Applications | New applications accepted Doctors can apply directly to the program Can NOT apply for a new application via phone Can NOT apply for a new application via fax Can apply for a new application via mail | |||||||||||||||
| Refills | Refills accepted Doctors can apply for refills Can NOT apply for refills via phone Can NOT apply for refills via fax Can apply for refills via mail | |||||||||||||||
| Re-Applications | Re-Applications accepted Doctors can apply for Re-Applications Can NOT Re-Apply via phone Can NOT Re-Apply via fax Can Re-Apply via mail | |||||||||||||||
| Appeals | Income Appeals accepted Patients can apply for Income Appeals Doctors can apply for Income Appeals Advocates can apply for Income Appeals Hardship Appeals accepted on a case by case basis Patients can apply for Hardship Appeals on a case by case basis Doctors can apply for Hardship Appeals on a case by case basis Advocates can apply for Hardship Appeals on a case by case basis | |||||||||||||||
| Eligibility | ||||||||||||||||
| Limitations | Patients are NOT eligible if LIS is denied Patients are eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are NOT eligible if they are accepting Medicare Patients are eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted | |||||||||||||||
| Appeals | ||||||||||||||||
| Conditions | Appeals may be consider out-of-pocket expenses on a case by case basis Appeals may be consider total medical expenses on a case by case basis | |||||||||||||||
| Other Medications | ||||||||||||||||
| Other Medications available in this program |
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