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Program Details

ASTELLAS
Astellas Support Solutions -Xtandi

Xtandi (enzalutamide)
 
CONTACT INFO
Address: PO Box 13185
La Jolla, CA 92039
Phone: 1-855-898-2634 Provider Phone:
Fax: 1-855-982-6341 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patients must not have insurance or is rendered uninsured.
  • Assistance may be available for those with Medicare and Medicare Part D.
  • 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:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: 30 days
    Delivery Time: Not Published
    Re-application Policy: Program will contact patient about re-applying.
    Refill Policy: Not Published
    Other Information: This program also provides copay assistance.

    Last Updated: 01/30/2024

     

     

     


    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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