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

Program 1 of 2.
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Updated April 10, 2014
Keppra

UCB Patient Assistance Program (Vimpat and Keppra XR)

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

Provided by: UCB, Inc.

PO Box 2198
Morrisville, PA 19067-0698

TEL: 866-395-8366


ALT PHONE:
FAX: 800-233-9141
Languages Spoken:

English, Spanish

Program Website
 

Patient Assistance Applications

UCB Patient Assistance Program Appliation for Vimpat and Keppra XR

 

Medications

  • Keppra Oral Solution 100mg/mL, 250mg/mL (levetiracetam)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Yes, if medication is not covered
Income Based on FPL
Diagnosis/Medical Criteria FDA-approved diagnosis.
US Residency Required? Yes, or legal alien
   

Application

Obtaining Call or download
Receiving Faxed or mailed
Returning Mail or fax
Doctor's Action Complete section, sign, attach prescription for 6 months
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Up to 6 months supply
Sent To Doctor's office
Delivery Time 1-2 business days
Refill Process New application needed
Limit Not specified
Re-application Every 6 months new application required
   

Additional Information

VIMPAT Copay Assistance Card Program: Savings of up to $45 toward each prescription (after paying the first $10) for up to 12 prescriptions per year for eligible patients. www.vimpate.com

KEPPRA Copay Assistance Card Program: Savings of up to $30 toward each prescription (after paying the first $25) for up to 12 prescriptions per year for eligible patients. www.keppraxr.com.

Contact program for Spanish application.



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

Program 2 of 2. Updated March 04, 2014
Keppra

Rx Outreach Medications

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

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


ALT PHONE: 888-RXO-1234
FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website
 

Patient Assistance Applications

Rx Outreach Application

Rx Outreach Diabetic Supplies

Rx Outreach Medication List

Rx Outreach Refills and New Prescriptions Order Form

 

Medications

  • Keppra Oral Solution 250mg, 500mg, 750mg (levetiracetam)
 

Eligibility Requirements

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed or mailed
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign
Decision Communicated Medications sent if accepted. If denied patient and Doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the website for the exact price.

Contact Program for Spanish Application(s)/Form(s)