rxhelp360.org
| Drug Information | |
| Drug | Theochron Tablets 100mg |
| Generic Equivalent | theophylline |
| Class | bronchodilator |
| Topic | Pulmo |
| 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 required Drivers license required Proof of Income required |
| Delivery of Medication | |
| Ship Time | 4-6 weeks |
| 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 | 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 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 apply for a new application via phone Can 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 apply for refills via phone Can apply for refills via fax Can NOT apply for refills via mail |
| Re-Applications | Re-Applications NOT accepted Patients can NOT apply for Re-Applications Doctors can NOT 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 |
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals NOT accepted Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can apply for an appeal via phone Can apply via fax Can NOT 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 eligible with existing prescription coverage Patients are NOT eligible if prescription is not covered Patients are NOT eligible if prescription coverage has been exhausted Patients are NOT 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 NOT eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted |
| Appeals | |
| Conditions | Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied |
| Other Medications | |
| Other Medications available in this program | |
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