It’s easy for patients to get started:
1. Complete the application
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. Attach the required financial documentation, including an original prescription.
Examples of the financial documents include:
- • IRS Form 1040, 1040EZ
- • IRS Form 4506T
- • Yearly Benefits Statement (SSA-1099)
- • Social Security Disability Statement
3. Submit the application by mail or fax
a. By mail:
Takeda Patient Assistance Program
PO Box 66552
St. Louis, MO 63166-6552
b. By fax: 1.800.497.0928
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 your healthcare provider will be notified by mail about your eligibility
status within five to seven days after Takeda receives the 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 for 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.