Program Contact Info / Application Submission
Program	Aciphex Patient Assistance Program
Company	EISAI Inc
Form	Download PDF
Address	PO Box 220458 Charlotte, NC 28222-0458
Phone	800-523-5870 (open 9-5 EST)
Fax	800-526-6651
Website	http://www.aciphex.com
Program Details
Details	30 and 90 day supplies are available and will be sent to the doctor�s office. Refills will automatically be sent out. Must re-apply every 12 months
Program Requirements
Information	The doctor and patient must complete respective portions of the form and attach any insurance information and a copy of most recent 1040 tax return.
Details	Insurance card required Drivers license NOT required Proof of Income required Letter from Doctor stating zero incomeNOT required as proof of income
Delivery of Medication
Ship Time	0-2 weeks
Delivery Options	Can NOT be delivered directly to the patient Can be delivered directly to the doctor
Application Process
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 apply for a new application via fax Can apply for a new application via mail
Refills	Refills accepted Patients can NOT apply for refills Doctors can apply for refills Advocates can NOT apply for refills Can NOT apply for refills via phone Can 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 Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals accepted 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 Can apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail
Eligibility
Eligibility	Patients must not have access to prescription drug coverage and must meet financial criteria. In all cases appeals are accepted.
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 prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients may be eligible if the medication is not covered under Medicare on a case by case basis Patients may be eligible if Medicare coverage has been exhausted on a case by case basis
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 Appeals must be made after the patient has been denied
Other Medications
Other  Medications  available in  this program	Aciphex - Acid Reflux Ulcer (Generic: rabeprazole sodium)