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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Tirosint

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IBSA Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Institut Biochimique SA (IBSA)

P.O. Box 1229
Southampton, PA 18966

TEL: 833-838-3247


FAX: 833-340-7196
Languages Spoken:

English

Program Website

 

Program Applications and Forms

IBSA Patient Assistance Program Enrollment Form

 

Medications

  • Tirosint capsule (levothyroxine)
 

Eligibility Requirements   

Insurance Status Must not have insurance
Those with Part D Eligible? No
Income At or below 200% of FPL, adjusted for household size
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be residing in the US or US territory
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified by phone and/or letter
Decision Timeframe Usually same day
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Patient's home, unless otherwise noted
Delivery Time Varies
Refill Process Patient requests refills via a toll-free number
Limit Not specified
Re-application Company contacts patient about reapplying
   

Additional Information

Contact program for details.

Updated March 08, 2021


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

Tirosint

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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 Application (Spanish)

Rx Outreach Refills Form

Rx Outreach Medication List (Alphabetized)

Rx Outreach Medication List (by Disease State)

Rx Outreach Diabetic Supplies Order Form (Prodigy)

 

Medications

  • levothyroxine (Tirosint capsule)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Determined case by case
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

Rx Outreach has expanded the eligibility guidelines beyond 400% FPL to include people affected by COVID-19.

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 March 29, 2021