| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 3. Scroll down to see them all. |
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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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3171 Riverport Tech Center Dr. TEL: 314-222-0472ALT PHONE: 888-796-1234 FAX: 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 (by Disease State) |
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Rx Outreach Medication List (by Disease State) (Spanish) |
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Rx Outreach Diabetic Supplies Order Form: Prodigy |
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Rx Outreach Diabetic Supplies Order Form: Prodigy (Spanish) |
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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, but contact program for details | ||
| 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 | ||
| 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 |
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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 | Varies | ||
| Re-application | Not applicable | ||
Additional Information |
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| 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 June 06, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 3. Scroll down to see them all. |
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Patient Access Network Foundation (PAN)This is a copay assistance program |
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Provided by: Patient Access Network Foundation |
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TEL: 866-316-7263FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Patient Access Network Foundation (PAN) Application: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| *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. |
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| Updated June 05, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 3. | |||
Supernus Support |
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Provided by: Supernus Pharmaceuticals, Inc. |
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TEL: 866-398-0833 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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Supernus Support Enrollment: Contact program |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Determined case by case | ||
| Those with Part D Eligible? | Determined case by case | ||
| Income | Varies | ||
| Diagnosis/Medical Criteria | Varies | ||
| US Residency Required? | Not specified | ||
Application |
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| Obtaining | Call | ||
| Receiving | Varies | ||
| Returning | Varies | ||
| Doctor's Action | Determine if patient is truly in need | ||
| Applicant's Action | Call for information or inform doctor that he/she is in need | ||
| Decision Communicated | Not specified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | Varies | ||
| Sent To | Varies | ||
| Delivery Time | Varies | ||
| Refill Process | Not specified | ||
| Limit | Not specified | ||
| Re-application | Varies | ||
Additional Information |
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| Call for most recent medications as the list is subject to change. Any patient who requires the medication and are in need should contact the program. Eligibility determined on a case-by-case basis. |
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| Updated June 06, 2023 | |||
