rxhelp360.org
| Program Contact Info / Application Submission | ||||||||||||||||||
| Program | DaiichiSankyo Pharma Open Care Program | |||||||||||||||||
| Company | Sankyo | |||||||||||||||||
| Form | Download PDF | |||||||||||||||||
| Phone | 866-268-7327 | |||||||||||||||||
| Fax | 866-217-7171 | |||||||||||||||||
| Program Requirements | ||||||||||||||||||
| Details | Insurance card required Drivers license required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero income required as proof of income Most recent check/check stub copy NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income | |||||||||||||||||
| Delivery of Medication | ||||||||||||||||||
| 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 apply for refills Doctors can apply for refills Advocates can apply for refills Applying for refills via phone will be considered on a case by case basis Can apply for refills via fax Can apply for refills via mail | |||||||||||||||||
| Re-Applications | Re-Applications NOT accepted Doctors can NOT apply for Re-Applications Can Re-Apply via phone Can Re-Apply via fax Can NOT Re-Apply via mail | |||||||||||||||||
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals 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 | |||||||||||||||||
| Eligibility | ||||||||||||||||||
| 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 Patients are NOT eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted | |||||||||||||||||
| 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 | |||||||||||||||||
| Other Medications | ||||||||||||||||||
| Other Medications available in this program |
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