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Eligibility
Application Process
1. Complete all patient and doctor sections of the application. The application is available by calling 1-800-830-9159 or by download at www.tpna.com/responsibility.2. Attach a copy of the patient's most recent year federal tax return or financial documentation.
3. Attach an original prescription.
4. If patient has applied to Medicaid within the past year and has been denied, attach a copy of the denial letter.
5. If patient is Medicare Part D eligible or enrolled, Section 5 or 6 must be completed.
6. Submit application and documentation by mail or fax
Application may be faxed: Yes from the physician's office only.
Eligibility determination letter sent: Yes to both Provider and Patient
Medication Info
Products available: PDFShipped to:Either Patient or Physician
Quantity in shipment: 90 days
Delivery time: 0-1 week
Reapplication policy: New application and financial information every 12 months
Medicare Part eligible/enrolled patients must re-enroll every calendar year
Refill policy: Yes
SOURCE: 2008 Poverty Chart
| Family Size | 100% | 133% | 150% | 200% | 250% | 300% |
| 1 | $10,830 | $14,404 | $16,245 | $21,660 | $27,075 | $32,490 |
| 2 | $14,570 | $19,378 | $21,855 | $29,140 | $36,425 | $43,710 |
| 3 | $18,310 | $24,352 | $27,465 | $36,620 | $45,775 | $54,930 |
| 4 | $22,050 | $29,327 | $33,075 | $44,100 | $55,125 | $66,150 |
| 5 | $25,790 | $34,301 | $38,685 | $51,580 | $64,475 | $77,370 |
| 6 | $29,530 | $39,275 | $44,295 | $59,060 | $73,825 | $88,590 |
| 7 | $33,270 | $44,249 | $49,905 | $66,540 | $83,175 | $99,810 |
| 8 | $37,010 | $49,223 | $55,515 | $74,020 | $92,525 | $111,030 |
| For each additional family member | $3,740 | $4,974 | $5,610 | $7,480 | $9,350 | $11,220 |
What´s Next?
Fill out the program enrollment form located to your right. If you don’t see an enrollment form available please call Takeda Patient Assistance Program program directly. After filling out the enrollment form please bring the form to your doctor for proper signatures and procedures. Do not forget a self stamped envelope for them to mail in your application to the program.
Other Tips
- If you have any questions please call the Takeda Patient Assistance Program program directly
- Fill out as much of the information on the enrollment form as possible. The more information you have pre-filled the easier the progrm is to enroll in
- Write down the refill dates for your program and set a reminder here on PatientAssistance.com so that you don’t run out of medication.
- Do not write messy on your forms as this will delay any response
- Call and write thank you notes to Takeda Patient Assistance Program program. Without their help millions of people will be without medication.
- PAP Links:
- Website:
- Address:
- Phone:
- Fax:
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List of Medications
ACTOplus Met Tablets 15mg/500mg, 15mg/850mg (metformin/pioglitazone), ACTOS Tablets 15mg, 30mg, 45mg (pioglitazone), Amitiza Capsules 8mcg, 24mcg (lubiprostone), Duetact Tablets 30/2mg, 30/4mg (pioglitazone/glimepiride), Rozerem Tablets 8mg (ramelteon), Prevacid 15mg, 30mg (lansoprasole), Prevacid SoluTab Tablets 15mg, 30mg (lansoprasole), ACTOS 15 Mg Tablet, ACTOS 30 Mg Tablet, ACTOS 45 Mg Tablet, ACTOplus Met 15 Mg/500 Mg Tablet, ACTOplus Met 15 Mg/850 Mg Tablet, AMITIZA 8 Mcg Capsule, AMITIZA 24 Mcg Capsule, Duetact 30 Mg/2 Mg Tablet, Duetact 30 Mg/4 Mg Tablet, Prevacid 15 Mg Capsule, Prevacid SoluTab 5 Mg Tablet, Prevacid 30 Mg Capsule, Prevacid SoluTab 30 Mg Tablet, Rozerem 8 Mg Tablet,KAPIDEX, Uloric 40 Mg Tablet, Uloric 80 Mg Tablet
Forms and other information are Copyright © Takeda Patient Assistance Program
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