Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 5.
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Azurity Solutions (Xatmep)

This program provides brand name medications at no or low cost

Provided by: Azurity Pharmaceuticals, Inc.

1710 N Shelby Oaks Dr. #1
Memphis, TN 38134

TEL: 844-472-2032


FAX: 866-927-2052
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Azurity Solutions (Xatmep) Patient Enrollment Form and Prescription

Azurity Solutions (Xatmep) Patient Assistance Program Form

 

Medications

  • methotrexate solution; oral (Xatmep) Solution; Oral
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Determined case by case
Income Based on FPL
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Download from website
Receiving 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 notified
Decision Timeframe Varies
   

Medication

Amount/Supply Varies
Sent To Patient's home, unless otherwise noted
Delivery Time Varies
Refill Process Contact program for details.
Limit Varies
Re-application Contact program for details.
   

Additional Information

Patient must sign the enrollment form to give the program permission to access their financial information in order to determine eligibility.

Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.

Updated May 06, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 5.
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Core Connections Program

This program provides brand name medications at no or low cost

Provided by: Medexus Pharmaceuticals, Inc.


TEL: 855-336-3322


ALT PHONE: 855-494-6489
FAX: 800-481-3325
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Core Connections Medexus Pharma Patient Assistance Program Application

Core Connections Patient Benefit Investigation Form

 

Medications

  • methotrexate injection; subcutaneous (Rasuvo) Injection; Subcutaneous
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Not specified
Income At or below 200% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Call or download
Receiving Sent to doctor or patient
Returning Fax from Doctor's office
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified
Decision Timeframe Within 24-48 hours
   

Medication

Amount/Supply Up to 1 month supply
Sent To Patient's home, unless otherwise noted
Delivery Time Not specified
Refill Process Contact program for details.
Limit Not specified
Re-application New enrollment every 6 months
   

Additional Information

Co-payment assistance, and patient assistance programs are available for eligible patients.

Updated March 09, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 5.
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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

  • methotrexate () 
  • methotrexate tablet (Rheumatrex) Tablet
 

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 4 of 5.
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HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation


TEL: 800-675-8416


Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program Enrollment: Contact program

HealthWell Foundation COVID-19 Ancillary Costs: Contact program

 

Medications

  • methotrexate injection; subcutaneous (Otrexup) Injection; Subcutaneous
  • methotrexate solution; oral (Xatmep) Solution; Oral
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

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.

Updated May 09, 2022


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

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

  • methotrexate injection
  • methotrexate solution; oral
  • methotrexate injection; subcutaneous
 

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 May 20, 2022