| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 2. Scroll down to see them all. |
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Tirosint |
View Coupon |
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IBSA Patient Assistance ProgramThis program provides brand name medications at no or low cost |
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Provided by: Institut Biochimique SA (IBSA) |
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P.O. Box 1229 TEL: 833-838-3247FAX: 833-340-7196 |
Languages Spoken:
English |
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Program Applications and Forms |
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IBSA Patient Assistance Program Enrollment Form |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| Contact program for details. |
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| 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 |
View Coupon |
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Rx Outreach MedicationsThis program provides medication at low cost. (Most brand names are provided for reference purposes only) |
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Provided by: Rx Outreach |
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PO Box 66536 TEL: 888-796-1234FAX: 800-875-6591 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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Rx Outreach Application
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Rx Outreach Application (Spanish)
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Rx Outreach Refills Form |
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Rx Outreach Medication List (Alphabetized)
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Rx Outreach Medication List (by Disease State)
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Rx Outreach Diabetic Supplies Order Form (Prodigy) |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| 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). |
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| Updated March 29, 2021 | |||
