| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 4. Scroll down to see them all. |
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Otsuka Patient Assistance Foundation (OPAF) Patient Assistance ProgramThis program provides medication at no cost. |
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Provided by: Otsuka Patient Assistance Foundation, Inc. |
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PO Box 501878 TEL: 855-727-6274FAX: 844-727-6274 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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Otsuka Patient Assistance Foundation (OPAF) Application Form: Abilify Maintena |
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Otsuka Patient Assistance Foundation (OPAF) Application Form: Jynarque |
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Otsuka Patient Assistance Foundation (OPAF) Application Form: Nuedexta |
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Otsuka Patient Assistance Foundation (OPAF) Application Form: Rexulti |
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Otsuka Patient Assistance Foundation (OPAF) Application Form: Samsca |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must be uninsured or underinsured | ||
| Those with Part D Eligible? | Varies | ||
| Income | Based on FPL | ||
| Diagnosis/Medical Criteria | FDA-approved diagnosis | ||
| US Residency Required? | Must be residing in the US or Puerto Rico | ||
Application |
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| Obtaining | Doctor/Doctor's office must call, download or apply online | ||
| Receiving | Complete online, download from website or faxed. | ||
| Returning | Fax, mail or submit online | ||
| Doctor's Action | Complete section, sign, attach required documents | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Doctor notified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | Varies | ||
| Sent To | Doctor's office or patient's home | ||
| Delivery Time | Not specified | ||
| Refill Process | Contact program for details. | ||
| Limit | Varies | ||
| Re-application | Varies | ||
Additional Information |
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| Updated March 14, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 4. 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 (Alphabetized) |
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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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| 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 May 23, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 4. Scroll down to see them all. |
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HealthWell Foundation Copay ProgramThis is a copay assistance program |
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Provided by: HealthWell Foundation |
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TEL: 800-675-8416 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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HealthWell Foundation Copay Program Enrollment: Contact program |
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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 | Varies | ||
| Diagnosis/Medical Criteria | FDA Approved Diagnosis - See Program Website for Details | ||
| US Residency Required? | Must reside in the US | ||
Application |
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| Obtaining | Call or complete online | ||
| Receiving | Varies | ||
| Returning | |||
| 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 |
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| 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 |
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| 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. |
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| Updated May 30, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 4 of 4. | |||
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 May 30, 2023 | |||
