| 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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Allergan Patient Assistance ProgramThis program provides brand name medications at no or low cost |
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Provided by: Allergan, Inc. |
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PO Box 66764 TEL: 844-424-6727FAX: 844-708-0036 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Allergan Patient Assistance Program Application |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Contact program for details. | ||
| Those with Part D Eligible? | Yes, but have been denied or are ineligible for Low Income Subsidy | ||
| Income | Not disclosed | ||
| Diagnosis/Medical Criteria | Medically appropriate condition/diagnosis | ||
| US Residency Required? | Must be US citizen or legal entrant | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed or downloaded from website | ||
| Returning | Fax or mail from Doctor'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 |
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| Amount/Supply | Up to 90 day supply | ||
| Sent To | Doctor's office or pharmacy | ||
| Delivery Time | Within 10 days | ||
| Refill Process | Doctor/Doctor's office must contact the Program | ||
| Limit | Varies | ||
| Re-application | Those with Medicare Part D reapply Jan 1st, all others reapply on anniversary date of when they enrolled | ||
Additional Information |
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| Proof of income is needed annually Letter of Medical Necessity must be included for Lexapro assistance |
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| Updated September 11, 2020 | |||
| 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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Takeda Help at Hand Patient Assistance ProgramThis program provides brand name medications at no or low cost |
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Provided by: Takeda Pharmaceutical |
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PO Box 5727 TEL: 800-830-9159FAX: 800-497-0928 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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Takeda Patient Assistance Program Application |
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Takeda Expands Assistance During COVID-19 Crisis Information Letter |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must have no coverage for the requested medication, be ineligible for federal or state programs | ||
| Those with Part D Eligible? | Yes | ||
| Income | At or below 500% of FPL | ||
| Diagnosis/Medical Criteria | Not specified | ||
| US Residency Required? | Yes | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax or mail from Doctor's office | ||
| Doctor's Action | Complete section, sign, attach prescription and include the DEA or state license number | ||
| Applicant's Action | Complete section, sign, attach a copy of proof of income | ||
| Decision Communicated | Patient and Doctor notified of acceptance | ||
| Decision Timeframe | 5-7 business days | ||
Medication |
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| Amount/Supply | Up to 90 day supply | ||
| Sent To | Doctor's office or patient's home | ||
| Delivery Time | Not specified | ||
| Refill Process | Not specified | ||
| Limit | Not specified | ||
| Re-application | New application, new documentation yearly | ||
Additional Information |
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| Applicants not approved for enrollment in the program may have the opportunity to seek an exception to the program criteria. |
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| Updated August 10, 2020 | |||
| 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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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 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 September 08, 2020 | |||
| 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 | Complete online or by phone | ||
| Doctor's Action | Will be discussed with patient and Doctor after request is received | ||
| Applicant's Action | Call for information or inform doctor that he/she is in need | ||
| Decision Communicated | Patient and Doctor notified in writing | ||
| Decision Timeframe | Within 48 hours | ||
Medication |
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| Amount/Supply | Not applicable | ||
| Sent To | Patient sent 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 September 01, 2020 | |||
