Application Requirements

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Application Requirements

AAP APPLICATION REQUIREMENTS

The Astellas Access ProgramSM (AAP) provides stock replacement of injectable medications, including VIBATIV that have been administered to eligible, uninsured patients who meet program guidelines. The number of product units administered to the patient will be sent to the provider’s office or hospital, at no cost to the healthcare provider.

The following information is required for each individual application for stock replacement.

Provider Information	Patient Information
Facility name Physician’s name, DEA, and state license number Facility contact’s name, phone, and fax number Name of the requested product Confirmation that the drug was administered for an appropriate FDA-approved indication OR one that is indicated in authoritative medical compendia Setting of care where the product was administered Address and setting of care for product shipment	Name and date of birth Home address and phone number Confirmation of the patient’s insurance status Household size and income

Once the healthcare provider has completed the one-page application (found in the Forms and Documents section), it should be submitted by fax to the Astellas Access ProgramSM at 1-866-317-6235 along with patient financial documentation. The application must be submitted to the Astellas Access ProgramSM within 180 days of the date of service for the last injection or infusion.

If the application is approved, you will receive replacement of the number of product units that were administered to the patient.

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PLEASE SEE INDICATION AND IMPORTANT SAFETY INFORMATION INCLUDING BOXED WARNING HERE.
PLEASE SEE FULL PRESCRIBING INFORMATION HERE AND MEDICATION GUIDE HERE.