Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 6.
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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

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

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 FDA-approved diagnosis
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 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 Varies
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Varies
Delivery Time Varies
Refill Process Patient or Doctor must contact company
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 May 09, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 6.
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myAbbVie Assist Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Allergan, 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: Contact program

 

Medications

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

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 FDA-approved diagnosis
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 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 Varies
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Varies
Delivery Time Varies
Refill Process Patient or Doctor must contact company
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 May 09, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 6.
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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 April 13, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 6.
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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

  • mesalamine retal suspension (Rowasa) Retal Suspension
 

Eligibility Requirements   

Insurance Status Determined case by case
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 Varies
Delivery Time Varies
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Eligibility determined on a case-by-case basis.
Contact program for details.

Updated March 29, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 5 of 6.
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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 Application (Spanish)

Rx Outreach Refills Form

Rx Outreach Medication List (Alphabetized)

Rx Outreach Medication List (by Disease State)

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

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 April 04, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 6 of 6.
 

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 April 25, 2022