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Daiichi Sankyo Open Care Program

This program provides brand name medications at no or low cost

Provided by: Daiichi Sankyo, Inc.

PO Box 8409
Somerville, NJ 08876

TEL: 866-268-7327


FAX: 866-217-7171
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Daiichi Sankyo Open Care Program Enrollment Form

 

Medications

  • Azor (amlodipine besylate/olmesartan medoxomil)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? No
Income At or below 200% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Call
Receiving Faxed
Returning Fax or mail
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified of denial in writing
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to 90 day supply
Sent To Doctor's office
Delivery Time Within 2 weeks
Refill Process *See Additional Information section below
Limit Not specified
Re-application *See Additional Information section below
   

Additional Information

*Please refer to the Refill/Reorder Instructions on the application for details.


Updated August 22, 2017


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Rx Outreach Medications

This program provides medication at low cost. (Most brand names are provided for reference purposes only)

Provided by: Rx Outreach

PO Box 66536
St. Louis, MO 63166-6536

TEL: 888-796-1234


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Diabetic Supplies Order Form (Prodigy)

Rx Outreach Refills and New Prescription Form

Rx Outreach Medication List

 

Medications

  • Azor (amlodipine besylate/olmesartan medoxomil)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the Rx Outreach website for the exact price and most current medication list.

Contact Program for Spanish Application(s)/Form(s).


Updated October 03, 2017