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Program Details

UCB PHARMA, INC.
UCBCares

Keppra XR tablets (levetiracetam ER)
 
CONTACT INFO
Address: 1330 Enclave Parkway
Suite 125
Houston, TX, 77077
Phone: 1-844-599-2273 Provider Phone:
Fax: 1-855-880-5262 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must be uninsured or insured medically but with no prescription coverage.
  • Patients with certain Medicare Part D plans may be eligible and can apply to determine eligibility.
  • Online application available on Program Website.
  • 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
    Physician License #
    Required:
    Both DEA and State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Patient
    MEDICATION
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy: All approved patients will be subject to a reverification of continued eligibility every 90 days. Continued eligibility beyond the initial 24 months will require re-enrollment
    Refill Policy: Not Published
    Other Information:
  • Copay Assistance is also available.
  • Last Updated: 01/17/2024

     

     

     


    Application Forms
    & Instructions

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



     

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