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Actavis Patient Assistance Program

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

Provided by: Actavis, Inc.

PO Box 66764
St. Louis, MO 63166

TEL: 800-851-0758

FAX: 844-708-0036
Languages Spoken:


Program Website


Program Applications and Forms

Actavis Patient Assistance Program Application

Actavis Patient Assistance Program Application Instruction Letter & Product List



  • Viibryd tablet (vilazodone)
  • Viibryd tablet; titration pack (vilazodone)

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Yes, but have been denied or are ineligible for Low Income Subsidy
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be citizen or legal resident


Obtaining Call or download
Receiving Mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign, attach proof of income and other requested documentation
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Within 4 weeks


Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
Sent To Doctor's office
Delivery Time Within 4 weeks
Refill Process New prescription every 3 months
Limit One year
Re-application New application every 12 months

Additional Information

Updated November 12, 2015