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

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


FAX: 800-233-9141
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

UCB Patient Assistance Program Appliation for Vimpat and Keppra XR

UCB Patient Assistance Program Appliation for Vimpat and Keppra XR Instructions

 

Medications

  • Keppra oral solution (levetiracetam)
  • Keppra tablet (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 At or below 300% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Yes, or legal alien
   

Application

Obtaining Call or download
Receiving Faxed or mailed
Returning Fax or mail
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 New application every 6 months
   

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.


Updated April 08, 2016