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 September 11, 2014
 

RX Savings Program

This is a copay assistance program.

Provided by: Edgemont Pharmaceuticals, LLC


TEL: 888-594-4332


ALT PHONE:
FAX: 512-329-2094
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

 RX Savings Program: Contact program

 

Medications

  • bupropion Tablet 450mg (Forfivo XL)
 

Eligibility Requirements   

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Not specified
   

Application

Obtaining No application
Receiving Not applicable
Returning Not applicable
Doctor's Action Give prescription to patient
Applicant's Action Request card online or by phone
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not applicable
Sent To Not applicable
Delivery Time Not applicable
Refill Process Good for one year
Limit Maximum of 12 times in one year
Re-application Request a new card after one year
   

Additional Information

Patient is responsible for the first $28 of their copay and for any amount above their maximum savings benefit.

This offer expires December 31, 2014.


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 14, 2014
 

Wellbutrin XL Guarantee Program

This is a copay assistance program.

Provided by: Valeant Pharmaceuticals, Inc.

Direct Success Pharmacy
PO Box 279
Sea Girt, NJ 08750

TEL: 800-520-3185


ALT PHONE:
FAX: 866-468-8274
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Wellbutrin XL Enrollment Form

 

Medications

  • bupropion Tablet 150mg, 300mg (Wellbutrin XL)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes, if medication is not covered or those in the donut hole
Income Not Required
Diagnosis/Medical Criteria Not disclosed
US Residency Required? United States or Puerto Rico
   

Application

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

Medication

Amount/Supply 30 day supply
Sent To Patient's home
Delivery Time Within 10 days
Refill Process Patient contacts pharmacy
Limit Not specified
Re-application Not specified
   

Additional Information

Patients pay no more than $50 per month for each monthly refill.


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 11, 2014
 

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

 

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 4 of 4. Updated September 25, 2014
 

Xubex Patient Assistance Program

This program provides medication at low cost.

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

 

Patient Assistance Applications

Xubex Patient Assistance Program Registration Form

Xubex Patient Assistance Program Physician Order Sheet

 

Medications

  • bupropion Tablet 75mg, 100mg ()
  • bupropion Tablet; Extended Release 150mg, 300mg ()
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
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