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	Proof of Income required
Delivery of Medication
Ship Time	3-5
Delivery Options	Can be delivered directly to the doctor
Application Process
New Applications	Can apply for a new application via fax Can apply for a new application via mail
Re-Applications	Can Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals accepted Hardship Appeals accepted
Eligibility
Eligibility	Patients must not have access to prescription drug coverage and must meet financial criteria. In all cases appeals are accepted.
Limitations	Patients are eligible if LIS is denied Patients are NOT 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 eligible if they are accepting Medicare
Appeals
Conditions	Appeals will consider out-of-pocket expenses