Patient Responsibilities

Patient Responsibilities:

Patient must be uninsured or underinsured (Medicare or Commercial Insurance w/o prescription benefits) to qualify for the program.

Patient must be on a medication for 6 months or more.

Patient is required to complete and sign the Patient’s Enrollment Form provided by Salud A Su Alcance-Pharmacy Assistance Program (SASA-PAP) annually.

Patient must include proof of income with the Patient Enrollment Form

Prescription medications are not transferable; patient may not share or sell prescription medication provided through the Pharmacy Assistance Program.

Patient must notify SASA-PAP if there is any change in income, address, telephone number, medication, and insurance status.

An administrative fee not exceeding $5 per prescription or $25 maximum for multiple prescriptions will be charged to patients.
If at any time there are side effects or a change in usage, the patient must notify their provider immediately.

Patient Rights:

Patient’s provider must authorize patient’s enrollment into the program if patient is eligible for the program and the medication is available through the Patient Assistance Program.

The prescribing physician will dispense prescriptions directly to the patient.

Patient has the right to disenroll from SASA-PAP at any time
Patient disenrollment will not jeopardize any medical or prescription coverage that patient might be entitled to under other programs.
Patient will be not be discriminated based on race, gender, health condition, religion, sexual orientation, or the number of medication they are on. SASA-PAP will serve in the best interest of the patient.
Patient will be informed of any changes pertaining to the Pharmacy Assistance Program.
Patient will be provided with an interpreter when necessary.
Patient may call the Pharmacy Assistance Program at any time if there are any questions regarding the program. Any questions pertaining to the medications should be directed to the patient’s provider.

The following constitute acceptable Proof of Income:

Copy of Federal Income Tax Return

Copy of Pay Stub

Copy of Social Security Benefits Statement or Check

Letter from person providing resources to patient

and

Copy of Pay Stub from that person verifying income