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

Assure Program for Samsca

For Healthcare Professionals Only

Provided by: Otsuka America Pharmaceutical, Inc.

PO Box 220684
Charlotte, NC 28222-0684

TEL: 855-242-7787


ALT PHONE: 412-389-3114
FAX: 855-876-2627
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Assure Program for Samsca Participating Pharmacies List

 

Brand Name Medications Covered

 
  • Samsca
 

Generic Name

 
  • tolvaptan
 

Eligibility Requirements   

Insurance Status *Contact program for details.
Those with Part D Eligible? Not specified
Income Household income at or below 300% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be a US resident and treated by a US licensed healthcare provider
   

Application

Obtaining Hospital contacts program when preparing to discharge a patient.
Receiving Faxed, mailed or downloaded from website
Returning Fax or E-Prescribe online
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Patient and Doctor are notified
Decision Timeframe Same Day
   

Medication

Amount/Supply Varies
Sent To Varies
Delivery Time Varies
Refill Process Not specified
Limit Varies
Re-application Not specified
   

Additional Information

This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY.

*This is a Postdischarge program: For patients continuing treatment when leaving the hospital, through a network of select specialty pharmacies.

Contact the program for details or call Christina, the Osuka Hospital Account Manager (412) 389-3114.


Updated September 29, 2017