Program Contact Info / Application Submission
Program	Gabitril Patient Assistance Program
Company	CephalonG
Address	c/o InTeleCenter PO Box 4280 Gaithersburg, MD 20885-4280
Phone	866-209-7589
Fax	866-209-7596
Program Details
Details	A coupon is sent to the patient for a 90-day supply. The company automatically sends out refills. Once a year a new application with financial documentation is needed.
Program Requirements
Information	The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application and attach proof of income.
Details	Insurance card NOT required Drivers license NOT required Proof of Income required on a case by case basis 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 Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income Notarized statement from patient stating zero income required as proof of income
Other Requirements	Letters must be notarized
Delivery of Medication
Ship Time	48hrs.
Delivery Options	Can be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card
Application Process
App Process	The doctor/doctor's office must call for a prescreening. The application will be faxed out. The completed application can be faxed or mailed back. The patient is notified of eligibility for the program.
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 NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can NOT apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail
Re-Applications	Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can 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 NOT accepted Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail
Eligibility
Eligibility	The patient must have no prescription coverage, have reached his/her cap or cannot afford the co-payments and have an income at or below 200% of the Federal Poverty Level. The patient must also be taking the medication for an on-label diagnosis. The patient must also be a US resident. If patient is eligible for Medicare Part D but did not enrolled, then they are not eligible for this program.
Limitations	Patients are NOT 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 NOT 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 will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied