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Ucb patient assistance program pdf

Ucb patient assistance form pdf 2026

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The UCB Patient Assistance Program Application provides financial assistance to eligible patients in the U.S. who require access to specific UCB medications, including CIMZIA®, BRIVIACT®, VIMPAT®, NEUPRO®, and KEPPRA®. To qualify, patients must meet certain medical and financial criteria, such as being uninsured or having no prescription coverage, and their household income must not exceed 300% of the Federal Poverty Limit. The application process requires completion by both the patient and their prescribing physician, along with necessary documentation to verify eligibility.

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Click ‘Get Form’ to open the UCB Patient Assistance Program Application in the editor.
Begin by completing Section 1, which requires patient information. Ensure all fields are filled clearly, including name, address, phone number, and date of birth. If applicable, provide a valid driver’s license number.
Proceed to Section 2 for income information. List all sources of gross monthly household income and ensure you sign and date this section. Remember that proof of income must accompany your application.
In Section 3, have your physician complete the prescription information. This includes their contact details and a valid prescription for the requested UCB product.
Review all sections for completeness before submitting your application through our platform. Ensure that all required signatures are present to avoid delays.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the Keppra patient assistance program?

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.

How much does Rilutek cost?

from $2,211.00 QuantityPer unitPrice 60 $36.85 $54.16 $2,211.00 $3,249.55

What is the Rilutek patient assistance program?

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.

What is the phone number for UCB patient assistance?

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.

How can I get Briviact for free?

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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What is the income limit for Novo Nordisk patient assistance program?

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?

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.

Who is eligible for the GSK patient assistance program?

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.