Program Contact Info / Application Submission
Program	Keppra Patient Assistance Program
Company	UCB Pharma
Form	Download PDF
Address	PO Box 2198 Morrisville, PA 19067-0698
Phone	866-395-8366
Fax	800-233-9141
Website	http://www.ucb.com/
Program Requirements
Details	Insurance card NOT required Drivers license NOT 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 Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer 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 Notarized statement from patient stating zero income required as proof of income
Other Requirements	Diagnosis specific
Delivery of Medication
Ship Time	2-4 weeks
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 NOT 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 Can NOT apply for refills via phone Can NOT apply for refills via fax Can 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 NOT Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals NOT accepted Hardship Appeals NOT accepted
Eligibility
Limitations	Patients may be eligible with existing prescription coverage on a case by case basis Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients may be eligible if they are accepting Medicare part D on a case by case basis Patients are eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted
Appeals
Conditions	Appeals will NOT consider out-of-pocket expenses
Other Medications
Other  Medications  available in  this program	Keppra - anticonvulsant Neuro/ Mental Health (Generic: levetiracetam)