Patient Assistance and Coverage Support

ACT Patient Assistance

An ACT Program Specialist will help your patient apply for the Patient Assistance Program, which provides EMEND free of charge to eligible patients without insurance coverage.* Eligible patients must complete the appropriate enrollment form and send it to the ACT program.

Qualification for Patient Assistance
To be eligible for patient assistance, your patient must meet certain criteria:

Your patient must live in the United States (he or she does not have to be a US citizen) and have a prescription for EMEND from a doctor licensed in the United States.

AND

Your patient must not have insurance or other coverage options for EMEND.*

AND

Your patient cannot afford to pay for EMEND.

In addition, household net income, geographic location of the patient, and number of people in the household are factors in determining the patient's eligibility.

Individuals who have insurance still may qualify for Patient Assistance if both they and their physicians attest that the patients have special circumstances of financial and medical hardship and their income is not above a set upper limit.

Contacting ACT for Patient Assistance
Your patients or office staff can contact the ACT program at 1-866-363-6379 to begin the enrollment process. Enrollment forms sent via fax or mail will also be accepted.

Phone:	1-866-363-6379
Fax:	1-866-363-6389

After faxing the completed enrollment form, promptly mail the signed original enrollment form to the ACT address provided below. Signed original enrollment forms must be received for all patients who receive EMEND through the Patient Assistance Program. Delivery of EMEND will not be delayed to qualified patients for the first shipment; however, refills will not be shipped until we receive the original signed enrollment form.

Mail:
Qualified patients will have EMEND delivered free of charge to their homes within 48 to 72 hours of receipt of the completed and signed enrollment forms. Forms should be mailed to: