Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 4.
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Updated December 11, 2014
 

Imitrex

Rx Outreach Medications

This program provides medication at low cost.

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


ALT PHONE:
FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

Rx Outreach Application

Rx Outreach Diabetic Supplies

Rx Outreach Refills and New Prescriptions Order Form

Rx Outreach Medication List

 

Medications

  • Imitrex Tablet 25mg, 50mg, 100mg (sumatriptan succinate)
 

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 or mailed
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)


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 4.
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Updated October 22, 2014
 

Imitrex

Bridges to Access

Provided by: GlaxoSmithKline

PO Box 29038
Phoenix, AZ 85038-9038

TEL: 866-728-4368


ALT PHONE:
FAX: 1-855-474-3063
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

 Bridges to Access Application: Contact program

 

Medications

  • Imitrex Spray; Nasal 5mg units, 20mg units (sumatriptan)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income At or below 250% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or Mail. (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office. Submit COPIES of Proof of Household income documents. Do not mail original income or tax documents. Documents submitted can not be returned.)
Doctor's Action Fax in prescription
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe Within 2-3 days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home, doctor's office, or the advocate's facility
Delivery Time Not specified
Refill Process Patient must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

Patients may apply on their own or with the help of an advocate. Fax or mail enrollment documents to the program with patient name and date of birth on each page (faxed prescriptions are only valid if faxed directly from a prescriber's office). Eligible patients may receive 90 day supply of medicine to their home within 7 days of faxed enrollment (mailed enrollments may take longer to receive medicine).
If enrollment documents are submitted by mail, submit ONLY COPIES of Proof of Household Income documents. Do not mail original income or tax documents. Documents submitted cannot be returned.

Please visit www.BridgesToAccess.com for more information.

This program does not constitute health insurance. Contact program for Spanish application.



Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 4.
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Updated December 16, 2014
 

Imitrex

GSK Access

Provided by: GlaxoSmithKline

PO Box 52046
Phoenix, AZ 85072-2046

TEL: 866-518-4357


ALT PHONE:
FAX: 866-518-3994
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

 GSK Access Application: Contact program

 

Medications

  • Imitrex Spray; Nasal 5mg units, 25mg units (sumatriptan)
 

Eligibility Requirements   

Insurance Status Must have Medicare Part D
Those with Part D Eligible? Yes, Must have Medicare Part D
Income At or below 250% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must live in one of the 50 states, the District of Columbia, or Puerto Rico and utilize the US healthcare system
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or Mail. (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office. Submit COPIES of Proof of Household income documents. Do not mail original income or tax documents. Documents submitted can not be returned.)
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified in writing
Decision Timeframe Within 2-3 days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home
Delivery Time Not specified
Refill Process Patient must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

If enrollment documents are submitted by mail, submit ONLY COPIES of Proof of Household Income documents. Do not mail original income or tax documents. Documents submitted cannot be returned.

This program does not constitute health insurance.

Contact program for Spanish application.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 4. Updated December 17, 2014
 

Imitrex

GSK Reimbursement Resource Center

Provided by: GlaxoSmithKline

PO Box221425
Charlotte, NC 28222-0265

TEL: 800-745-2967


ALT PHONE:
FAX: 866-216-5292
Languages Spoken:

English, Others By Translation Service

Program Website

 

Patient Assistance Applications

GSK Reimbursement Authorization Form

 

Medications

  • Imitrex Spray; Nasal dosage varies (sumatriptan)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Determined case by case
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Not specified
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

This program helps patients and healthcare professionals with coverage, reimbursement and coding issues for certain GSK products.  Services include verification of benefits, and assistance with prior authorization processes, denied or underpaid claims,  coding issues, and alternate funding research.