Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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Cosopt

Akorn Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Akorn, Inc.


TEL: 844-202-5909


FAX: 844-500-5254
Languages Spoken:

English

Program Website

 

Program Applications and Forms

 Akorn Patient Assistance Program Application: Contact program

 

Medications

  • Cosopt ophthalmic solution/drops (dorzolamide/timolol maleate)
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be a US resident
   

Application

Obtaining Call
Receiving Faxed or mailed
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Call to enroll
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home, unless otherwise noted
Delivery Time Not specified
Refill Process Not specified
Limit Maximum of 3 refills through one year from date on original prescription
Re-application Not specified
   

Additional Information


Updated August 19, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Cosopt

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

Rx Outreach Medication List (Spanish)

 

Medications

  • Cosopt (dorzolamide/timolol maleate)
 

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 July 28, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

Cosopt

Xubex Patient Assistance Program

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

Provided by: Xubex

PO Box 1244
Winter Park, Fl 32790-1244

TEL: 866-699-8239


ALT PHONE: 407-478-2663
FAX: 407-671-7960
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Xubex Patient Assistance Program Registration Form (pages 1 & 2)

Xubex Patient Assistance Program Physician Order Sheet (page 3)

 

Medications

  • Cosopt (dorzolamide/timolol maleate)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes, but contact program for details
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Varies per medication
Re-application New application, new documentation yearly
   

Additional Information

No proof of income is required. Check the website for the exact price.

This service is not currently available in Montana.


Updated August 05, 2016