Program Contact Info / Application Submission
Program	Axcan Scandipiharm Patient Assistance Program
Company	AxcanSUrso
Address	22 Inverness Center Parkway Birmingham, AL 35242
Phone	1-866-292-2679
Website	http://www.scandipharm.com/carefirstform.php?lang=1
Program Details
Details	The patient is sent a pharmacy card to be used once a month. Once a year the application process must be repeated.There is a $3.00 dispensing fee for each prescription and, based on insurance coverage, there may be minor additional costs.
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
Other Requirements	$3 co-pay
Application Process
App Process	The doctor, patient, social worker or patient advocate must call for a prescreening. The application is sent to either the doctor or the patient. The completed application must be mailed back. The decision is made during the phone screening, then application is sent.
Eligibility
Eligibility	The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below 200% of the Federal Poverty Level. The patient must also be a US resident. Patients who do not meet the insurance guidelines but are in need should still call. There is a $3 dispensing fee at the pharmacy.