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

Xalatan

View Coupon View Coupon

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

  • Xalatan ophthalmic solution/drops (latanoprost)
 

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 2 of 3.
Scroll down to see them all.
 

Xalatan

View Coupon View Coupon

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

  • Xalatan (latanoprost)
 

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


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

Xalatan

View Coupon View Coupon

Pfizer Savings Program

Provided by: Pfizer, Inc.

PO Box 66585
St. Louis, MO 63166-6585

TEL: 866-706-2400


FAX: 866-470-1748
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Pfizer Medication List

 

Medications

  • Xalatan (latanoprost)
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income Varies
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be residing in the US or US territory
   

Application

Obtaining Call
Receiving Not specified
Returning Not specified
Doctor's Action Not specified
Applicant's Action Call
Decision Communicated Not specified
Decision Timeframe Varies
   

Medication

Amount/Supply Varies
Sent To Varies
Delivery Time Varies
Refill Process Varies per medication
Limit None
Re-application Not specified
   

Additional Information

In addition to providing free medicine through the Pfizer Patient Assistance Program, Pfizer has programs that provide eligible patients with insurance support, copay assistance, and medicines at a savings. To learn more about the program(s) that may be right for you, call Pfizer RxPathways to speak with a Medicine Access Counselor (844-989-7284)


Updated September 22, 2016