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Program Details

WARNER CHILCOTT PHARMACEUTICALS
Patient Assistance Program

Enablex (darifenacin)
 
CONTACT INFO
Address: PO Box 66553
St. Louis, MO 63166-6553
Phone: 1-800-830-9049 Provider Phone:
Fax: 1-866-277-9329 Website:
ELIGIBILITY
Eligibility Info:
  • THIS PROGRAM IS NOT CURRENTLY ACCEPTING NEW APPLICATIONS.
  • To be eligible for this program, patients must fall within the eligibility criteria below and must not have affordable coverage for the medication.
  • If the patient is eligible to enroll in a Medicare prescription drug plan and has income below 150% FPL, the patient must document that she or he does not qualify for a Medicare drug subsidy "extra help".
  • Income at or below: Single 200 % FPL
      Couple 200 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
      Credit for Dependents allowed
    Medical expenses can be deducted from reported income: No
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Prescription
    Physician License #
    Required:
    Either DEA or State
    Prescriber Signature
    Allowed:
    Any Health Care Prescriber
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Provider
    If patient is denied eligibility, a letter will be sent to the patient within 14 days.
    MEDICATION
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: 90 days
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    Refill Policy: 3 refills
    A new prescription is needed for each refill.
    Other Information:

    Last Updated: 10/15/2012

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Instructions (English)



     

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