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Program Details

TAKEDA PHARMACEUTICALS U.S.A.
Help At Hand
Dexilant (dexlansoprazole)
 
CONTACT INFO
Address: P.O. Box 5727
Louisville, KY 40255-0727
Phone: 1-800-830-9159 Provider Phone:
Fax: 1-800-497-0928 Website: Takeda PAP website
ELIGIBILITY
Eligibility Info:
  • Patient must not have health coverage, does not have enough coverage to obtain the medication or does not have access to alternate sources of coverage or funding.
    • Income at or below: Single 500 % FPL
      Couple 500 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: No
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    NJ & NY physician's must include a prescription
    Physician License #
    Required:    		 State
    Prescriber Signature
    Allowed:    		 Physician
    Application may be
    faxed:    		 Yes
    Eligibility determination
    letter sent:    		 Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: 90 days
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Not Published
    Other Information:

    Last Updated: 02/26/2024

    		  

     

     


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


    DocumentForm (English)

     

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