Fycompa Patient Assistance Program

Funded

About

The Fycompa Patient Assistance Program offers eligible US residents access to the drug Fycompa at no or low cost. This program is tailored to assist financially needy patients by providing them with the necessary medication, ensuring they meet specific eligibility criteria. Enrollment is straightforward with required documentation, and the assistance lasts up to one year before renewal is needed.

Insurance requirements: Underinsured, Uninsured

Enrollment Forms

Enrollment Form

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: Yes

•Activation Required: No

Program Details

•The FYCOMPA Patient Assistance Program provides FYCOMPA at no or low cost to financially needy patients who meet program eligibility criteria

•Patients must download & fax completed enrollment form to 18446338444, including physician and insurance information

•Financial documentation (e.g. federal tax returns, social security benefit statements, one month's worth of paycheck stubs) must also be submitted

•Notice of acceptance or denial will be mailed to the patient and faxed to the physician

•Enrollment in the FYCOMPA Patient Assistance Program is valid for up to one year, at which time a new enrollment form must be submitted for an eligibility determination of continued need

•For questions, call 18883926674 Monday Friday 8AM5PM

Enrollment Forms

Enrollment Form

Other Programs

Assistance Fund: Epilepsy (Seizures): Waitlist

Commercially Insured

Medicare / Medicaid

Underinsured

Uninsured

Fycompa Instant Savings Card - Covered benefit

Coverage Required

Commercially Insured

Medicare / Medicaid

Underinsured

Uninsured

Max Saving: $250012/year*

Pay as low as

$5/ mo

Other Tools for Fycompa

Get prior authorization forms

Get patient education materials