Program Details
INTERCEPT PHARMACEUTICALS, INC.
Interconnect Support Services Patient Assistance Program
Ocaliva
(obeticholic acid tablet)
|
CONTACT
INFO |
|
Address: |
PO Box 580
Somerville, NJ , 08876 |
Phone: |
1-844-622-4278 |
Provider Phone: |
|
Fax: |
1- 855-686-8730 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient must not have prescription drug coverage for Ocaliva.
Patients with Medicare Part D should contact the program for details.
Program provides co-payment assistance, reimbursement support, and patient assistance programs for eligible patients. |
Income at or below: |
Single |
|
500
% FPL |
|
Couple |
|
500
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
No |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Patient
|
Quantity in
Shipment: |
Amount requested is sent |
Delivery Time: |
Not Published
|
Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
Refill Policy: |
Program contacts patient to arrange |
Other Information: |
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|
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Last Updated: 02/15/2024
www.RxAssist.org
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