Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Mission Pharmaceutical Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Mission Pharmacal Company

Customer Services
PO Box 786099
San Antonio, TX 78278-6099

TEL: 800-292-7364


FAX: 800-681-4050
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Mission Pharmaceutical Patient Assistance Program: Contact program

 

Medications

  • acetohydroxamic acid tablet (Lithostat)
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income At or below 100% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be citizen
   

Application

Obtaining Doctor's office needs to send letter indicating patient needs this medication, duration, diagnosis, patient name, contact name, phone and fax numbers
Receiving Sent to Doctor's office
Returning Fax or mail from Doctor's office
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Not applicable
Decision Communicated Doctor notified
Decision Timeframe 7-10 business days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Doctor's office
Delivery Time Within 2 weeks
Refill Process Doctor's office sends copy of letter with new dates and any change in dosage. Must be at least 3 weeks prior to prescription running out. In some cases new application may be needed
Limit Not specified
Re-application New application every 3 months
   

Additional Information

Contact the program for more details (1-800-292-7364).


Updated July 31, 2017


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

Mission Product Request

For Healthcare Professionals Only

Provided by: Mission Pharmacal Company


TEL: 877-425-0325


ALT PHONE: 800-531-3333
FAX: 877-426-2795
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Mission Product Request: Contact program

 

Medications

  • acetohydroxamic acid tablet (Lithostat)
 

Eligibility Requirements   

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not disclosed
US Residency Required? Not specified
   

Application

Obtaining The Doctor should call for an application or download it from the website
Receiving Faxed to Doctor's office
Returning Fax from Doctor's office
Doctor's Action Complete section and sign
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Doctor contacts company
   

Additional Information

Resources for HEALTHCARE PROFESSIONAL ONLY.
The Doctor must contact the program to place an order.


Updated September 21, 2017