Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 5.
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Teva Cares Foundation Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Teva

PO Box 52028
Phoenix, AZ 85072

TEL: 877-237-4881


FAX: 877-438-4404
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Teva Cares Foundation Patient Assistance Program Application

 

Medications

 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? No
Income Based on FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must permanently reside in the US and be under the direct care of a US Physician
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail (Note: faxed prescriptions are only valid if faxed directly from a prescriber's office)
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 5-7 business days
Refill Process Reorder form needs to be submitted
Limit Varies
Re-application New application yearly
   

Additional Information

Call for most recent medications as the list is subject to change.

Updated November 14, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 5.
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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

3171 Riverport Tech Center Dr.
Maryland Heights, MO 63043

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 Medication List (by Disease State) (Spanish)

Rx Outreach Diabetic Supplies Order Form (Prodigy)

 

Medications

  • albuterol sulfate aerosol; inhalation (ProAir HFA) Aerosol; Inhalation
  • albuterol sulfate tablet (Proventil) Tablet
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes, but contact program for details
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
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Patient and/or Doctor are 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 Varies
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 September 26, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 5.
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HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation


TEL: 800-675-8416


Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program Enrollment: Contact program

HealthWell Foundation COVID-19 Ancillary Costs: Contact program

 

Medications

  • albuterol sulfate aerosol; inhalation
  • albuterol sulfate tablet
  • albuterol sulfate inhalation solution; oral
  • albuterol sulfate tablet; extended release
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes, but contact program for details
Income Varies
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Varies
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Automatically sent out
Limit Contact the program for details
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 November 28, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 5.
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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


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

 

Medications

  • albuterol sulfate aerosol; inhalation (Ventolin HFA) Aerosol; Inhalation
 

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 FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Not applicable
Doctor's Action Varies
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor are notified
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient is sent savings 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 November 28, 2022


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

HarborPath ADAP Waiting List Program

For Healthcare Professionals Only

Provided by: HarborPath, Inc.


TEL: 855-300-8916


FAX: 888-237-9831
Languages Spoken:

English

Program Website

 

Program Applications and Forms

HarborPath ADAP Waiting List Program Enrollment Form

 

Medications

  • albuterol sulfate tablet (Proventil) Tablet
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income Determined case by case
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax from Doctor's office
Doctor's Action Enroll in program, complete form and obtain patient consent
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Within 24-48 hours
   

Medication

Amount/Supply Varies
Sent To Patient's home, unless otherwise noted
Delivery Time Once approved; within 2 business days
Refill Process Doctor/Doctor's office must contact the Program
Limit Varies
Re-application Contact program for details.
   

Additional Information

Resources for HEALTHCARE PROFESSIONALS ONLY.

Patients are eligible for the HarborPath ADAP Waiting List Program if they: Meet eligibility for the ADAP Waiting List Program in their state of residency; and have a confirmation letter from their state ADAP indicating patient is on the ADAP waiting list.

Typical eligibility requirements do not apply to the ADAP Waiting List Program.

Updated September 06, 2022