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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Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • hydrocortisone () 
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Updated July 10, 2015


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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Pfizer RxPathways Patient Assistance Program

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

Provided by: Pfizer, Inc.

PO Box 66585
St. Louis, MO 63166-6585

TEL: 866-706-2400


FAX: 866-470-1748
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Pfizer Group A Application for Primary Care Medicines

Pfizer Group A Application for Primary Care Medicines (Spanish)

Pfizer Group B Application for Oncology and Specialty medicines

Pfizer Group B Application for Oncology and Specialty medicines (Spanish)

Pfizer Group C Application for Vaccines

Pfizer Group C Application for Vaccines (Spanish)

 

Medications

  • hydrocortisone tablet (Cortef) Tablet
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Not specified
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining Call or download
Receiving Mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 4 weeks
   

Medication

Amount/Supply Varies
Sent To Address of shipment varies by medication *See Additional Information section below
Delivery Time Within 2-4 weeks
Refill Process Patient or Doctor must contact company
Limit None
Re-application New application, new documentation yearly
   

Additional Information

This program also offers a Savings Card Program: Card activation is required.

*Lyrica, oral oncology, and specialty products are shipped to the patient's home, other medications to Doctor's office

For help with Prevnar 13, please contact customer service and talk to your health care provider. This program was formerly known as Pfizer Helpful Answers


Updated August 26, 2015


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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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


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Diabetic Supplies

Rx Outreach Refills and New Prescriptions Order Form

Rx Outreach Medication List

 

Medications

  • hydrocortisone tablet () Tablet
 

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 15, 2015


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 4.
 

Salix Pharmaceuticals Patient Assistance Program

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

Provided by: Salix Pharmaceuticals

PO Box 66520
St Louis MO 63166-6520

TEL: 866-282-6563


FAX: 877-738-3694
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Salix Pharmaceuticals Patient Assistance Program Application

Salix Patient Assistance Program Application for Fulyzaq

Salix Patient Assistance Program Application for Fulyzaq (Spanish)

Salix Patient Assistance Program Application for Xifaxan 550

Salix Diabetes Patient Information Form

Salix Ulcerative Colitis Patient Information Form

 

Medications

  • hydrocortisone cream (Anusol-HC) Cream
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? Varies
Income At or below 200% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must have a verifiable US or US territory address (no PO Box)
   

Application

Obtaining Call or download
Receiving Sent to doctor or patient
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Within 2 weeks
   

Medication

Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
Sent To Patient's home
Delivery Time Within 2 weeks
Refill Process Refill/reorder form included with shipment
Limit None
Re-application New application yearly
   

Additional Information

May have Medicare Part D and Must be at or below 500% FPL for Fulyzaq and Xifaxan.

Contact program for Spanish application.
Updated July 10, 2015