Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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myAbbVie Assist Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: AbbVie Inc.

PO Box 270
Somerville, NJ 08876

TEL: 800-222-6885


FAX: 866-483-1305
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

myAbbVie Assist Patient Assistance Program Application

myAbbVie Assist Patient Assistance Program Application (Spanish)

 

Medications

  • levothyroxine tablet (Synthroid) Tablet
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? Varies
Income At or below 600% of FPL
Diagnosis/Medical Criteria Not applicable
US Residency Required? Must be a US resident and treated by a US licensed healthcare provider
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
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 Patient and Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Varies
Delivery Time Varies
Refill Process Contact program for details.
Limit Varies
Re-application Varies
   

Additional Information

Any patient who requires the medication and are in need should call the company. Eligibility determined on a case-by-case basis. Patients with prescription drug coverage may be eligible on exception basis.

Contact program for details.

Updated August 14, 2023


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Viatris Patient Assistance Program (Group One Medicines)

This program provides brand name medications at no or low cost

Provided by: Viatris Inc.


TEL: 888-417-5780


FAX: 877-427-7290
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Viatris Patient Assistance Program (Group One Medicines) Application

Viatris Patient Assistance Program (Group One Medicines) Application: Clozapine

 

Medications

  • levothyroxine oral solution (Ermeza) Oral Solution
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured with no prescription coverage for needed medication
Those with Part D Eligible? Not specified
Income Determined case by case
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Email or fax
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Doctor's office
Delivery Time Varies
Refill Process Contact program for details.
Limit Contact the program for details
Re-application Contact program for details.
   

Additional Information

Eligibility determined on a case-by-case basis.

Contact program for details.

Updated December 06, 2023


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

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: 314-222-0472


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Application (Spanish)

Rx Outreach Medication List (by Disease State)

Rx Outreach Medication List (by Disease State) (Spanish)

Rx Outreach Diabetic Supplies Order Form: Prodigy

Rx Outreach Diabetic Supplies Order Form: Prodigy (Spanish)

 

Medications

  • levothyroxine capsule (Tirosint)
  • levothyroxine tablet (Levoxyl)
 

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 Not applicable
   

Additional Information

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 December 04, 2023