| Pharmaceutical Company | Aricept Patient Assistance Program |
| Program Address | Pfizer & Eisai, Inc. P. O. Box 25457 Alexandria, VA 22313-5457 |
| Toll Free Phone Number | 800-226-2072 |
| Alternate Phone Number | None |
| Fax Number | None |
| Guidelines and Notes | This program is different from the other Pfizer programs. Patients with no dependents must earn less than $25,000 per year. Patients with dependents must earn less than $40,000 per year. Calls for questions are accepted 8:30-5:30 Eastern Time. When a form is sent, information on local and national Alzheimer's Disease resources for caregivers and patients is included. |
| Initiating Enrollment | Anyone can enroll the patient by phone. At the time of registration patient income and insurance information is required. The form is sent only to the physician. |
| Health Provider's Role | The doctor completes and signs the form. The prescription is incorporated into the form and a separate one is not needed. Information on whether or not the patient has prescription coverage must be completed. The form may be faxed or mailed in the postage paid envelope provided. |
| Patient's Role | No additional patient involvement. The doctor's office might have the insurance information on file. |
| How Dispensed | The medicine is sent to the doctor's office. |
| Amount Dispensed | 90 day supply |
| Estimated Response Time | Not specified |
| Refills | Call them to request a Requalification Form one month prior to completing the current shipment of drugs. The doctor must call for the form; it won't be automatically sent. |
| Limit | Indefinite |