Program

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Program 1 of 3 Scroll down to see them all.

This program provides brand name medications at no or low cost.
Pharmaceutical Company	Medtronic, Inc.
Program Name	ITB Therapy Patient Assistance Program
Program Address	Medtronic ITB Therapy Patient Assistance Program NORD 55 Kenosia Avenue P.O. Box 1968 Danbury, CT 06813-1968
Phone Number	800-999-6673, opt 3, opt 1216
Fax Number	203-798-2964
Medications on Program	Lioresal intrathecal 10mg/20ml, 10mg/5 ml, 0.05mg/1ml (baclofen injection)
Application Forms	Not Applicable
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	The patient must have no prescription coverage for the requested medication and meet income and other eligibility guidelines that are not disclosed. The patient must be diagnosed with Spasticity. The patient must also be a US resident or legal alien. A negative decision can be appealed. Patients may not be a Medicaid recipient nor covered under Medicare.
Application Process	Anyone with the patient's and the doctor's information can call. The application is sent to the doctor's office. The completed application can be faxed or mailed back. The estimated timeline is 3-5 business days.
Application Requirements	The doctor must fill out a section, sign the application and attach a prescription. The patient must fill out a section, sign the application and attach proof of income.
Program Details	The medication is sent to the doctor's office. The patient or doctor must contact the company for refills. Once a year a new application with financial documentation is needed.
Last Updated	August 05, 2010

Program 2 of 3 Scroll down to see them all.

This program provides generic medications at a discount.
Pharmaceutical Company	Express Scripts Specialty Distribution Services
Program Name	Rx Outreach Medications
Program Address	PO Box 66536 St Louis, MO 63166-6536
Phone Number	800-769-3880
Fax Number
Medications on Program	baclofen Tablet 10mg, 20mg (Lioresal)
Application Forms	Rx Outreach
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	Applicants with insurance are eligible. have an income at or below 300% of the Federal Poverty Level. Medical diagnosis necessary for this program is not specified. US residency requirements are not specified. This program is for generic medications only. Many medications are available for a fee of $20 for up to a 180 day supply. Prices vary for Tier 2 and Tier 3 medications. Please refer to the Rx Outreach website for more information.
Application Process	Anyone requesting assistance can call to request a faxed application or download it from the website. The application can be either faxed or mailed out upon request. The completed application must be mailed back. The patient is notified of eligibility for the program.
Application Requirements	The doctor needs to provide a prescription to the patient. The patient must fill out a section and sign the application.
Program Details	The medication is sent to either the doctor's office or the patient's home. The patient must contact the company to arrange for refills. Every year a new application is needed.
Last Updated	July 08, 2010

Program 3 of 3.

This program provides generic medications at a discount.
Pharmaceutical Company	Xubex Pharmaceuticals
Program Name	Xubex Patient Assistance Program
Program Address	PO Box 1244 Winter Park, Fl 32790-1244
Phone Number	866-699-8239
Fax Number	407-671-7960
Medications on Program	baclofen Tablets 10mg, 20mg (Lioresal)
Application Forms	Xubex Patient Assistance Program
On-line Application	No on-line application available at this time
Web Site	Click to go to program's web site
Eligibility Guidelines and Notes	Applicants with insurance are eligible. This program does not have income limitations. Medical diagnosis necessary for this program is not specified. US residency requirements are not specified. This is a program for generic medications only. There are fees for the medications:$20-$45 for a 90 day supply. ($40 or $60 for a 180 day supply and $80 or $120 for a 360 day supply.) Check the website for the exact price. A shipping and ordering fee of $3.85 is charged for each order. Patients may apply online or print the prescription, complete and fax to the Xubex pharmacy for processing. Requests may be expedited by having the physician fax the completed form to the Xubex pharmacy.
Application Process	Anyone requesting assistance can call to request a faxed application or download it from the website. The application will be faxed out. The completed application can be faxed or mailed back. The medication is shipped within 10 business days.
Application Requirements	The doctor needs to provide a prescription to the patient. The patient must fill out a section and sign the application.
Program Details	The medication is sent to either the doctor's office or the patient's home. The company automatically sends out refills. Once a year a new application with financial documentation is needed.
Last Updated	August 04, 2010