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| Drug Information | |
| Drug | Namenda Tablet 5mg |
| Generic Equivalent | memantine hcl |
| Class | NMDA-receptor antagonist |
| Topic | Alzheimers |
| Program Contact Info / Application Submission | |
| Program | Forest Pharmaceuticals Inc. Patient Assistance Program |
| Company | Forest |
| Form | Download PDF |
| Address | 13645 Shoreline Drive, St. Louis, MO 63045 |
| Phone | 800-851-0758 |
| Fax | NA |
| Website | http://www.forestpharm.com/pap |
| Program Details | |
| Details | Up to a 90-day supply is shipped to the doctor�s office. A new application is required for all refills. |
| Program Requirements | |
| Information | Doctors must fill out their section, sign the application and attach a valid prescription. Patients must fill out their section and sign the application. |
| Details | Insurance card NOT required Drivers license NOT required Proof of Income NOT required |
| Delivery of Medication | |
| Ship Time | 4-6 weeks |
| Delivery Options | Can NOT be delivered directly to the patient Can be delivered directly to the doctor |
| Application Process | |
| App Process | Anyone concerned may call and request an application. Applications will be faxed out. Completed applications must be mailed back. If the patient is denied, both the patient and doctor are notified in writing. Please allow up to 4 weeks for processing and delivery of medication. |
| 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 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 Patients can apply for refills Doctors can apply for refills Advocates 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 Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates 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 Patients can apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can apply for an appeal via mail |
| Eligibility | |
| Eligibility | Patients can have no prescription coverage for the medication being requested and meet income guidelines which are not disclosed. The address on the prescription must matche the mailing address on the application. If this is not the case, letterhead must be attached to verify the delivery address. If the patient is Medicare Part D elligible and does not enroll they may still be eligible for assistance in this program. |
| Limitations | Patients are NOT eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients may be eligible if they are accepting Medicare part D on a case by case basis Patients are eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted |
| Appeals | |
| Conditions | Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals must be made after the patient has been denied |
| Other Medications | |
| Other Medications available in this program | |
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