For patients prescribed SAMSCA® (tolvaptan), ASSURE offers assistance withinsurance coverage, prior authorization support, copay, and more.
Connect With a Dedicated Patient Support Manager (PSM)
As part of ASSURE enrollment, a PSM is available to help review coverage and access options for each of your patients, request benefit verification or reverification, and connect patients to resources to help with continuity of care.
For assistance with enrollment,
please call 1-855-242-7787,
8 AM - 8 PM ET, Monday - Friday.
Both you and your patient will need to fill out different sections of the enrollment form.
It may be easiest to complete the form together if possible.
Download Enrollment Form
Once downloaded, complete the enrollment form with your patient. You can fill the form out in the PDF or by hand. When finished, send the form to ASSURE one of two ways:
For a quicker response, we recommend
you fax the enrollment form to:
Mail the enrollment form to:
Otsuka America Pharmaceutical, Inc.
PO Box 3040
Gaithersburg, MD 20885-3040