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

Dexilant

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Takeda Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Takeda Pharmaceuticals America, Inc.

PO Box 5727
Louisville, KY 40255-0727

TEL: 800-830-9159


FAX: 800-497-0928
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Takeda Patient Assistance Program Application

 

Medications

  • Dexilant capsule (dexlansoprazole)
 

Eligibility Requirements   

Insurance Status Must have no coverage for the requested medication, be ineligible for federal or state programs
Those with Part D Eligible? Yes
Income At or below 400% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section, sign, attach prescription and include the DEA or state license number
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified of acceptance
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information

Applicants not approved for enrollment in the program may have the opportunity to seek an exception to the program criteria.

*Brintellix (vortioxetine) Renamed Trintellix (vortioxetine) in U.S. to Avoid Name Confusion. Healthcare providers can still prescribe Brintellix. The newly named Trintellix will be available in June 2016.


Updated September 09, 2016