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| Drug Information | ||||||||||
| Drug | Ultrase MT 20 powder | |||||||||
| Topic | Organs | |||||||||
| Program Contact Info / Application Submission | ||||||||||
| Program | ASSIST Program | |||||||||
| Company | Axcan Pharma | |||||||||
| Address | PO Box 52065, Phoenix, AZ 85072-9152 | |||||||||
| Phone | 866-292-2679 | |||||||||
| Program Details | ||||||||||
| Details | The patient is sent a pharmacy card, which is to be used once a month. The application process must be repeated once a year. | |||||||||
| Program Requirements | ||||||||||
| Information | Both the doctor and patient must fill out their section and sign the application. | |||||||||
| Details | Insurance card required Drivers license required | |||||||||
| Other Requirements | There is a $3.00 dispensing fee for each prescript | |||||||||
| Delivery of Medication | ||||||||||
| Delivery Options | Can NOT 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 either the doctor or the patient. Completed applications must be mailed back. The decision is made during the phone screening and then application is sent. | |||||||||
| New Applications | New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can NOT 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 NOT accepted | |||||||||
| 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 | |||||||||
| Eligibility | ||||||||||
| Eligibility | Patients can not have any prescription insurance, not be ineligible for any government programs, in addition, the must have an income at or below 200% of the Federal Poverty Level. | |||||||||
| Other Medications | ||||||||||
| Other Medications available in this program |
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