Drug:

 
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