Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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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

  • mometasone furoate (Elocon) 
 

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 2 of 2.
 

Organon Connect

For Healthcare Professionals Only

Provided by: Organon


TEL: 844-674-3200


Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Organon Connect Product Information: Contact program

 

Medications

  • mometasone furoate aerosol; inhalation (Asmanex HFA) Aerosol; Inhalation
  • mometasone furoate powder; inhalation (Asmanex Twisthaler) Powder; Inhalation
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Determined case by case
Income Not disclosed
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Not specified
Receiving Not specified
Returning Not specified
Doctor's Action Enroll in the program
Applicant's Action Not applicable
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Resources for HEALTHCARE PROFESSIONALS ONLY.

The Physician must register to access tools and materials for patient support, product sample requests, and up-to-date professional resources.

Updated April 19, 2022