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Astellas Pharma Support Solutions

This program provides brand name medications at no or low cost

Provided by: Astellas Pharma, Inc.

PO Box 13185
La Jolla, CA 92039

TEL: 800-477-6472


Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Astellas Pharma Support Solutions Authorization Form

 

Brand Name Medications Covered

 
  • AmBisome injection
  • Myrbetriq tablet; extended release
  • Astagraf XL capsule; extended release
  • Prograf
  • Lexiscan solution; iv
  • VESIcare tablet
  • Mycamine injection
 

Generic Name

 
  • amphotericin B liposome injection
  • solifenacin tablet
  • micafungin sodium injection
  • tacrolimus
  • mirabegron tablet; extended release
  • tacrolimus capsule; extended release
  • regadenoson solution; iv
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? No
Income At or below 250% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis or authorized compendia listing
US Residency Required? Must have a verifiable US shipping address and be treated by US Doctor
   

Application

Obtaining Call, download or apply online
Receiving Downloaded from website
Returning Submitted online by health care provider
Doctor's Action Complete and submit an Astellas Access Program application via Astellas eService at www.astellasreimbursement.com
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Not specified
Re-application New application yearly
   

Additional Information

Please visit www.astellaspharmasupportsolutions.com for more information

This program also provides copay assistance.


Updated August 16, 2017