Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Updated October 20, 2014
 

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

PO Box 5727
Louisville, KY 40255

TEL: 800-830-9159


ALT PHONE:
FAX: 800-497-0928
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Takeda Patient Assistance Program Application

 

Medications

  • Dexilant Capsule 30mg, 60mg (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? Considered on exception basis
Income At or below 300% 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.

Contact program for Spanish application.