Briviact

Indicated For

partial onset seizures, epilepsy

About This Medication

# UCB Patient Assistance Program Guide: How to Get BRIVIACT at Low or No Cost ## About BRIVIACT BRIVIACT (brivaracetam) is a prescription anticonvulsant medication used to treat partial seizures in people with epilepsy. It belongs to a class of drugs called pyrrolidone derivatives and works by helping to reduce abnormal electrical activity in the brain that causes seizures. BRIVIACT is manufactured by UCB, Inc., a pharmaceutical company committed to helping patients access their medications. ## What Is the UCB Patient Assistance Program? The UCB Patient Assistance Program is a free program offered directly by the manufacturer to help uninsured and underinsured patients obtain BRIVIACT at no cost or reduced cost. If you're struggling to afford this medication, this program may help you get the treatment you need without the financial burden. ## Who Can Apply? You may be eligible for the UCB Patient Assistance Program if you meet these criteria: - **You have a valid prescription** from a U.S. licensed healthcare provider for BRIVIACT - **You are a U.S. resident** and a citizen or permanent resident - **You are uninsured**, OR - **You have insurance but no prescription drug coverage**, OR - **You have certain Medicare Part D plans** that don't adequately cover BRIVIACT - **Your household income** does not exceed program limits (see income table below) The program is designed to help those who cannot afford their medication due to financial hardship. Even if you have insurance, you may qualify if your out-of-pocket costs are too high. ## Income Eligibility Guidelines Your household income must be at or below the maximum amounts shown in this table. Income limits are based on the Federal Poverty Level guidelines. | Household Size | Maximum Annual Income | |---|---| | 1 person | Varies* | | 2 people | Varies* | | 3 people | Varies* | | 4 people | Varies* | | 5 people | Varies* | | 6 people | Varies* | | 7 people | Varies* | | 8+ people | Varies* | *Income thresholds are based on current Federal Poverty Level guidelines and may change annually. Contact the program directly at **(844) 599-2273** to confirm your eligibility based on your household size and income. ## Insurance Requirements You may qualify if: - You have **no health insurance** at all - You have health insurance **but no prescription drug coverage** - You have **Medicare Part D coverage** but face high out-of-pocket costs due to coverage gaps ("donut hole") or plan limitations - Your insurance plan has a **high deductible or copay** that makes BRIVIACT unaffordable Note: If you have other insurance that covers BRIVIACT, you should use that coverage first. The patient assistance program is designed as a last resort for those without adequate coverage options. ## Documents You'll Need to Apply Before you start your application, gather these important documents: 1. **Valid prescription** from your U.S. licensed doctor for BRIVIACT 2. **Proof of income** (signed by you) — examples include: - Recent tax return - Pay stubs from the past 30 days - Benefit statement (Social Security, unemployment, etc.) - Signed letter from employer stating your salary 3. **Valid government-issued ID** — such as: - Driver's license - Passport - State ID card 4. **Completed application** with sections 1 and 2 filled out by you (the patient) 5. **Physician authorization** — Section 3 of the application must be completed and signed by your prescribing doctor ## Step-by-Step Application Instructions ### Step 1: Download the Application Visit the program website at **https://www.briviact.com/briviact-patient-assistance-program.pdf** to download the application form, or call **(844) 599-2273** to request one by mail. ### Step 2: Complete Your Patient Information Fill out sections 1 and 2 of the application with: - Your full name, date of birth, and contact information - Your household size and income details - Insurance information (if applicable) - Details about your financial need - Your signature and today's date ### Step 3: Give the Form to Your Doctor Provide your prescribing physician with section 3 of the application. Your doctor will need to: - Confirm your BRIVIACT prescription details - Verify the medical necessity of the medication - Sign and date the form - Return it to you (or submit directly to UCB if they prefer) ### Step 4: Submit Your Application You can submit your completed application using multiple methods: - **Mail** to the address listed on the application form - **Phone** — Call **(844) 599-2273** to submit or ask about online submission options - **Fax** — Check the application for the fax number Include all required documents with your application. Incomplete applications will delay processing. ### Step 5: Wait for Approval Typically, applications are reviewed and approved within **4-8 weeks**. You'll be contacted by phone or mail with the decision. If approved, you'll receive instructions on how to obtain your medication. ## Timeline and Medication Delivery Once your application is approved, your BRIVIACT will be delivered through a **specialty pharmacy**. This means: - A specialty pharmacy partner will fill your prescription - Your medication will be shipped directly to your home or a location you choose - You should receive it within 7-10 business days of approval - You may need to speak with a pharmacist when you receive your medication for counseling ## What Happens if My Application Is Denied? If your application is denied, don't lose hope. You can: 1. **Ask why** — Request a detailed explanation from the program 2. **Appeal** — Ask if you can reapply with additional documentation 3. **Explore alternatives** — See the section below for other options 4. **Talk to your doctor** — Your healthcare provider may be able to help you find other resources ## Annual Reauthorization If you're approved for the program, your assistance is not permanent. **You must reauthorize your eligibility every year** by submitting updated income documentation and completing the reauthorization form. The program will notify you when it's time to renew. ## Other Assistance Options ### BRIVIACT Savings Card If you have insurance that covers BRIVIACT, a savings card may help reduce your copay: - Visit **https://www.briviact.com/savings-activation** to activate your card - Show your card at the pharmacy to reduce out-of-pocket costs - This can work alongside your insurance plan ### Additional Resources If you don't qualify for the manufacturer program: - Contact your state's pharmaceutical assistance program - Visit **NeedyMeds.org** for lists of other patient assistance programs - Ask your healthcare provider about generic alternatives or other seizure medications - Contact local nonprofit organizations that help people with epilepsy, such as the Epilepsy Foundation ## Questions? We're Here to Help **UCB Patient Assistance Program** - **Phone:** (844) 599-2273 - **Website:** https://www.briviact.com/briviact-patient-assistance-program.pdf The program staff can answer questions about eligibility, help you with your application, and provide updates on your status. Don't hesitate to call — they're there to help you. ## Important Legal Disclaimer This guide is for informational purposes only and does not constitute medical advice or a guarantee of program eligibility. Eligibility requirements, income limits, and program policies are subject to change. For the most current and accurate information about the UCB Patient Assistance Program, visit the official program website or call the phone number listed above. Always consult with your healthcare provider about your medication and treatment options. This medication should only be used as prescribed by your doctor. --- *Last Updated: 2024 | Program Information Subject to Change*

Program information last verified: March 25, 2026