Ucb patient assistance form pdf 2025

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Program information: The KeppraⓇ Patient Assistance Program is intended to provide temporary assistance to patients who do not qualify for or have benefits through private insurance or a government funded program, and who do not have other sufficient means to pay for their medication.
from $2,211.00 QuantityPer unitPrice 60 $36.85 $54.16 $2,211.00 $3,249.55
The Rilutek Patient Assistance Program is designed to help the uninsured and people in need better afford their prescription medicines, subject to financial restrictions. How to Apply: Select one of the links below to download the application or go to the program site for more information on how to apply.
If you believe you do not meet the minimum requirements listed above, please contact UCBCares by calling 844-599-CARE (2273) to determine whether other financial resources may be available to you.
The BRIVIACT Patient Assistance Program may provide medication at no cost to eligible patients who are unable to pay for their BRIVIACT prescription. To find out if you might be eligible for assistance, please call UCBCares at 844-599-CARES (2273) or email ucbcares@ucb.com.
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Be a US citizen or legal resident. Have a total household income at or below 400% of the federal poverty level. Must be uninsured, or have Medicare. Note: if you have private or commercial insurance, you are not eligible for the PAP.
How does Rilutek work? The active substance in Rilutek, riluzole, acts on the nervous system. The exact way in which it works in ALS is not known. It is thought that the destruction of nerve cells in motor neuron disease may be caused by too much of the neurotransmitter glutamate.
You might be eligible if all of the following are true: You have a commercial medical or prescription insurance plan. You are a resident of the US (including the District of Columbia, Puerto Rico, and the US Islands) You are not eligible for, or enrolled in, a government-funded program.

ucb patient assistance application