Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

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Sunovion Support Prescription Assistance Program (Aptiom)

This program provides brand name medications at no or low cost

Provided by: Sunovion Pharmaceuticals, Inc.

PO Box 220285
Charlotte, NC 28222-0285

TEL: 877-850-0819


FAX: 877-850-0821
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Sunovion Support Prescription Assistance Program (Aptiom) Application

Sunovion Request for Transcript (Aptiom): Tax Return Form 4506-T

 

Medications

  • Aptiom tablet (eslicarbazepine acetate)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income At or below 300% of FPL
Diagnosis/Medical Criteria Must provide diagnosis code
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining Call or download
Receiving Mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within a week
   

Medication

Amount/Supply 30 day supply
Sent To Pharmacy
Delivery Time 1-3 business days
Refill Process Automatically filled at pharmacy
Limit Maximum of 11 refills in one year
Re-application New application yearly
   

Additional Information


Updated July 12, 2017