rxhelp360.org
| Drug Information | ||||||||||||||
| Drug | Rozerem | |||||||||||||
| Class | Sleep | |||||||||||||
| Topic | Insomnia | |||||||||||||
| Program Contact Info / Application Submission | ||||||||||||||
| Program | Takeda Patient Assistance Program | |||||||||||||
| Company | Takeda | |||||||||||||
| Form | Download PDF | |||||||||||||
| Address | PO Box 66552 St. Louis, MO 63166 | |||||||||||||
| Phone | 800-830-9159 | |||||||||||||
| Fax | 800-497-0928 | |||||||||||||
| Website | http://www.tpna.com/patasstProgram.asp | |||||||||||||
| Program Details | ||||||||||||||
| Details | Medication will be sent to the patient�s home. For Rozerem, a new prescription is needed for every refill. For Actos/Actoplus met, refills are automatically sent out for up to 1 year (prescription allowing). For all other medications, a new prescription is required every 3 months. The patient can call in refills if the prescription allows. Must re-apply with a new application and documentation every year. Actos Puerto Rico residents, please contact the program at 800-830-9159. | |||||||||||||
| Program Requirements | ||||||||||||||
| Information | Both the patient and physician must fill out respective sections of the application. A prescription, financial documentation, and Medicaid denial letter (if denied within the past year) must be attached. | |||||||||||||
| 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 Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements NOT required as proof of income | |||||||||||||
| Other Requirements | ||||||||||||||
| Delivery of Medication | ||||||||||||||
| Ship Time | 5-7 business days | |||||||||||||
| Delivery Options | Can NOT be delivered directly to the patient Can NOT be delivered directly to the doctor | |||||||||||||
| Application Process | ||||||||||||||
| New Applications | New applications NOT accepted Patients can NOT apply directly to the program Doctors can NOT apply directly to the program Advocates can NOT apply directly to the program Can NOT apply for a new application via fax Can NOT apply for a new application via mail | |||||||||||||
| Refills | Refills NOT accepted Patients can NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can NOT apply for refills via phone | |||||||||||||
| Re-Applications | Re-Applications NOT accepted Patients can NOT 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 Re-Apply via mail | |||||||||||||
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals accepted Patients can apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can NOT apply for an appeal via phone Can apply via fax Can apply for an appeal via mail | |||||||||||||
| Eligibility | ||||||||||||||
| Eligibility | The patient must be a legal US resident, have no prescription coverage for any medications, and have an income at or below 200% of the Federal Poverty Level. Patients eligible for Medicare Part D but not enrolled may be eligible for this program but must send in a letter of denial from the Social Security Program for consideration. | |||||||||||||
| Limitations | Patients may be eligible if LIS is denied on a case by case basis Patients are NOT eligible with existing prescription coverage Patients are eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D | |||||||||||||
| Other Medications | ||||||||||||||
| Other Medications available in this program |
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