RxAssist Home
RxAssist Home Home  |  About Us  |  Contact RxAssist          
      Patient Assistance Program Center
 
 

Program Details

OTSUKA AMERICA PHARMACEUTICAL, INC.
Otsuka Patient Assistance Foundation

Abilify Maintena injection (aripiprazole)
 
CONTACT INFO
Address: PO Box 4530
Chesterfield, MO 63006
Phone: 1-855-727-6274 Provider Phone:
Fax: 1-844-727-6274 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Contact program for details or use the eligibility tool on program website.
  • Eligibility is based on federal poverty guidelines.
  • Healthcare providers can complete application online.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Physician License #
    Required:
    State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Provider
    MEDICATION
    Receives:
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy: Not Published
    Refill Policy: Not Published
    Other Information:

    Last Updated: 02/08/2024

     

     

     


    Application Forms
    & Instructions

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


    Document Abilify Application


    Document Jynarque Application


    Document Rexulti Application


    Document Nuedexta Application


    Document Samsca Application



     

    Print-friendly version

    This information is for informational purposes only and is not meant to be a substitute for professional medical advice, diagnosis or treatment. Neither RxAssist nor RxVantage is offering advice, recommending or endorsing any specific prescription drug, pharmacy or other information on the site. Neither RxVantage nor RxAssist provide any warranty for any of the pricing data or other information. Please seek medical advice before starting, changing or terminating any medical treatment. Third party logos, trademarks, brand names and images contained on rxassist.org or rxvantage.com are for demonstration purposes only and are owned by their respective rights holders, who are not affiliated with this Site.

    Copyright © 2024, RxVantage, all rights reserved.