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| Program Contact Info / Application Submission |
| Program | Aricept Patient Assistance Program | | Company | EISAIAri | | Form | Download PDF | | Address | PO Box 679 Somerville, NJ 08876 | | Phone | 800-226-2072 | | Fax | 800-226-2059 | | |
| Program Details |
| Details | Up to a 90-day supply is sent to the doctor's office. A new application is needed for each refill.
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| Program Requirements |
| Information | The doctor must fill out a section and sign the application. The patient must fill out a section and sign the application.
| | Details | Proof of Income NOT required
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| Delivery of Medication |
| Delivery Options | Can NOT be delivered directly to the doctor
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| Application Process |
| App Process | With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application can be faxed or mailed back. The doctor is notified of acceptance or denial. Allow 10 business days for processing and delivery of medication | | |
| Eligibility |
| Eligibility | The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below $25,000 if single ($40,000 for a family). The medication must be used for outpatient use only. The patient must also be a US resident.
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| Other Medications |
Other
Medications
available in
this program | |
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