Program Applications

Tips for using the applications:

  • You will need Adobe Reader to open the applications. Download this free program or the latest version, which is recommended.
  • Click the button in the top right of the application to turn on the Highlight Fields Option which will highlight the fields to be filled out.
  • Use the "tab" key to easily go to the next field.

As of 12/14/2017 there are 614 applications available.

Click on the first letter of the name of the program. Then click on the application for that program. Dates next to each listing reflect the last update. Some applications may need to be opened with a different viewer depending on which browser you are using. Firefox users may get a message saying "This PDF document might not be displayed correctly." Try clicking on the "Open With Different Viewer" option. If you are still unable to interactively complete the application, use a different browser.

Send the completed application to the address on the application and not to NeedyMeds.

If you cannot find an application or are having trouble printing one, contact the program or company.

Contact NeedyMeds if you find any content errors.

For link problems or other technical problems, send an email to webmaster.

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Xelsource Medical Necessity Sample Letter 05/25/17
Xelsource Patient Assistance Application for Xeljanz 05/25/17
Xelsource Prescription & Enrollment Form 05/25/17
Xelsource Provider Authorization and Confidentiality Agreement Form 05/25/17
Xenazine Treatment Form 07/13/17
Xeomin Patient Assistance Program Enrollment Form 04/25/17
Xeomin Patient Assistance Program Insurance Verification Request Form 04/25/17
Xeomin Patient Savings Program Application 04/26/17
Xeomin Safety Information 04/26/17
Xiaflex Copay Savings Program Reimbursement Form 08/14/17
Xiaflex Patient Assistance Program Application 08/14/17
Xiaflex Prescription and Benefits Investigation Form 08/14/17
Xofigo Access Services Benefit Verification Request Form 03/23/17
Xofigo Access Services Intake Form 03/23/17
Xofigo Access Services Intake Form for use by VA/DoD Only 03/23/17
Xofigo Patient Assistance/Commercial Copay Assistance Form 03/23/17
Xtampza ER Financial Assistance Program Enrollment Form
Xyrem Patient Assistance Program: Contact program

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