Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 4.
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Allergan Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Allergan, Inc.

PO Box 66764
St. Louis, MO 63166

TEL: 844-424-6727


FAX: 844-708-0036
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Allergan Patient Assistance Program Application

 

Medications

  • mesalamine capsule; delayed release (Delzicol) Capsule; Delayed Release
  • mesalamine suppository; rectal (Canasa) Suppository; Rectal
 

Eligibility Requirements   

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

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

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

Proof of income is needed annually

Letter of Medical Necessity must be included for Lexapro assistance


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.
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Takeda Help at Hand Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Takeda Pharmaceutical

PO Box 5727
Louisville, KY 40255-0727

TEL: 800-830-9159


FAX: 800-497-0928
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Takeda Patient Assistance Program Application

Takeda Expands Assistance During COVID-19 Crisis Information Letter

 

Medications

  • mesalamine capsule; controlled-release (Pentasa) Capsule; Controlled-Release
  • mesalamine tablet; delayed release (Lialda) Tablet; Delayed Release
 

Eligibility Requirements   

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

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

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

Applicants not approved for enrollment in the program may have the opportunity to seek an exception to the program criteria.

Updated August 10, 2020


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

PO Box 66536
St. Louis, MO 63166-6536

TEL: 888-796-1234


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Refills Form

Rx Outreach Medication List (Alphabetized)

Rx Outreach Medication List (by Disease State)

Rx Outreach Diabetic Supplies Order Form (Prodigy)

 

Medications

  • mesalamine tablet; delayed release (Lialda) Tablet; Delayed Release
 

Eligibility Requirements   

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

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

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

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 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

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

  • mesalamine
  • mesalamine capsule; extended release
  • mesalamine capsule; controlled-release
  • mesalamine suppository; rectal
  • mesalamine capsule; delayed release
  • mesalamine tablet; delayed release
 

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 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

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

*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 September 01, 2020