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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


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Program 2 of 2.
 

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Sunovion ProFile (FOR HEALTHCARE PROFESSIONAL ONLY)

For Healthcare Professionals Only

Provided by: Sunovion Pharmaceuticals, Inc.

84 Waterford Drive
Marlborough, MA 01752

TEL: 888-394-7377


Languages Spoken:

English

Program Website

 

Program Applications and Forms

Sunovion ProFile: Contact program

 

Medications

  • Aptiom tablet (eslicarbazepine acetate)
 

Eligibility Requirements   

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be treated by US Doctor
   

Application

Obtaining Not specified
Receiving Not applicable
Returning Not applicable
Doctor's Action Determine if patient is truly in need
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not applicable
Limit Not specified
Re-application Not specified
   

Additional Information

HEALTHCARE PROFESSIONAL MUST REGISTER.


Updated July 12, 2017