1. Complete Sections 1, 2 and 3 of the application. You must sign Section 3.
Complete Section 4 if you are enrolled in Medicare D, or Section 5 if you are eligible but not
enrolled in Medicare Part D.
a. Download the application
b. Or call toll-free 1.800.830.9159 and choose option #2 to have an application faxed
or mailed
2. Verify your insurance and income in Section 2 of the application.
Very Important!
Remember to attach your financial documentation
from last year (IRS Form 1040 or 1040 EZ)*.
3. Have your healthcare provider complete Sections 6 and 7, and then submit the signed application with all your documentation.
| By Fax |
By mail: |
| 1.800.497.0928 |
Takeda Patient Assistance Program
P.O. Box 5727
Louisville, KY 40255-0727
|
Additional information and tips:
It’s very important that you fill out the application completely and make sure all the required information is included when you apply. If you have any questions, don’t hesitate to call 1.800.830.9159.
You and/or your healthcare provider will receive an answer from the Takeda Patient Assistance Program within five to seven days after we receive your application.
Upon approval, your medications will be delivered right to your home or your healthcare provider’s office, whichever you choose.
The enrollment will last up to one year or for those eligible or enrolled in Medicare Part D, through the end of the calendar year. After that time, you will need to reapply to continue participating in the program.
If your circumstances have recently changed, including but not limited to unemployment, please write a letter explaining your situation and include proof of unemployment if applicable. Examples of proof of unemployment may include: copy of unemployment check or statement, letter from previous employer, or support documentation of current income (e.g., spousal unemployment).
*If you do not have copies of last year’s federal income tax return, you must include a copy of: IRS Form 4506T, Social Security Yearly Benefits Statement (SSA-1099) or all income statements from jobs held last year.