Aricept Patient Assistance Program (PAP)

Aricept Patient Assistance Program (PAP)

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Aricept Patient Assistance Program (PAP)

Sponsor Organization
Eisai Inc

Prescription Medication Assistance Organization Contact
Aricept Patient Assistance Program (PAP)
1480 Arthur Avenue, Ste D
Louisville, CO 80027
Phone: (800) 226-2072
Fax: (800) 226-2059

Medications sent to: Patient’s Doctor

Prescription Medications/Products Covered:

Program Information And Resources:
Requalification Form

Program Information And Resources:
Qualification Form

Program Information And Resources:

Program Eligibility Requirements:
Eisai and Pfizer have established this program in order to assist as many needy patients as possible. Patients must meet certain eligibility criteria in order to qualify for assistance. There are five items that determine a patient’s Program Eligibility Requirements: 

Residency – Patient must be a United States resident. 

Site of care –Program is for outpatient use only. 

Income – Patient without dependents (single, widowed) must earn less than $25,000 annually. Patient with dependents (married) must earn less than $40,000 annually. 

Insurance – Patient who has no public or private prescription drug coverage, including Medicaid. 

Dosage – Daily dosage of Aricept should not exceed 10mg. Should a patient qualify, a 90-day supply of medication will be sent to the physician for distribution.

Additional Information and/or Requirements (known):
1. The physician must complete and sign the Qualification Form. Please note that the bottom portion of the form acts as the prescription and must be completed carefully.

2. Be sure to complete the patient’s information on the Qualification Form, and have the patient or patient’s caregiver sign the form in the patient’s signature section.

3. Be sure the patient signs and dates the Authorization to Disclose Information Form. The physician and patient should retain a copy of this signed and dated form for their records. 

4. Fax the signed, dated and completed Qualification Form and Authorization to Disclose Information Form to the Aricept Patient Assistance Program (PAP) at 1-800-226-2059 or mail the forms to us at the address above. * 

To receive an additional 90-day supply, the physician must complete the Re-Qualification form, and fax the signed, dated and completed form to the Aricept Patient Assistance Program (PAP) at 1-800-226-2059 or mail the form to the address above.







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