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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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

  • sucralfate suspension (Carafate) Suspension
 

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 January 11, 2021


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

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 Diabetic Supplies Order Form (Prodigy)

 

Medications

  • sucralfate suspension (Carafate) Suspension
 

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 December 16, 2020