| |
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 |
|
| 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 |
| Federal Poverty Level Calculator |
 |
| 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: |
|
|
|
Last Updated: 02/15/2024
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
Form (Spanish)
|
|
