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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Keppra

UCBCares Program

This program provides brand name medications at no or low cost

Provided by: UCB, Inc.

1330 Enclave Parkway
Suite 125
Houston, TX 77077

TEL: 877-785-8906


FAX: 855-880-5262
Languages Spoken:

English

Program Website

 

Program Applications and Forms

UCBCares Patient Assistance Program Application

UCBCares Brochure

 

Medications

  • Keppra (levetiracetam)
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured with no prescription coverage
Those with Part D Eligible? Determined case by case
Income At or below 300% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside in the US, District of Columbia, or Puerto Rico and have a prescription from a U.S. licensed doctor.
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Amount requested is sent
Sent To Patient's home, unless otherwise noted
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Once a year new application required. Financial documentation may be requested any time
   

Additional Information

CIMZIA: Call 1-866-424-6942

This program also provides copay assistance.


Updated October 11, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Keppra

Rx Outreach Medications

This program provides medication at low cost. (Most brand names are provided for reference purposes only)

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Diabetic Supplies Order Form (Prodigy)

Rx Outreach Refills and New Prescription Form

Rx Outreach Medication List

Rx Outreach Medication List (Spanish)

 

Medications

  • Keppra (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, mailed or downloaded from website
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and 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 Rx Outreach website for the exact price and most current medication list.

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


Updated November 15, 2016