Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 6.
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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

 

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.


Updated June 22, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 6.
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HealthWell Foundation Copay Program

This is a copay assistance program.

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

 HealthWell Foundation Copay Program: Contact program

 

Medications

  • hydrocortisone () 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated August 04, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 6.
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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

 Patient Access Network Foundation (PAN) Application: Contact program

Patient Access Network Foundation (PAN) Provider Brochure

Patient Access Network Foundation (PAN) Patient Brochure

 

Medications

  • hydrocortisone (Solu-Cortef) 
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% 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 Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
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

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

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.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.




Updated August 02, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 6.
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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

  • 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 28, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 5 of 6.
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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

  • hydrocortisone () 
 

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 6 of 6.
 

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

  • hydrocortisone (Cortef) 
 

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