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Amitriptyline Patient Assistance Programs

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Or go to the main Patient Assistance Programs page>>

: Apply for prescription assistance below


If you are eligible, the programs below can help you afford . Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.


If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.



Rx Outreach Medications


(Program 1 of 2. Scroll down to see them all.)

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 (PDF)
  • Rx Outreach Diabetic Supplies Order Form (Prodigy) (PDF)
  • Rx Outreach Medication List (PDF)
  • Rx Outreach Refills and New Prescription Form (PDF)

Medications

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? The patient must also be residing 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

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 6/27/2017

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HealthWell Foundation Copay Program


(Program 2 of 2. Scroll down to see them all.)

Provided by: HealthWell Foundation

PO Box 220410 Chantilly, VA 20153-0410

TEL: 800-675-8416
FAX: 800-282-7692

Languages Spoken:
English, Others By Translation Service
Program Website
 

Program Applications and Forms

  • HealthWell Foundation Copay Program: Contact program

Medications

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? The patient must also be residing in the US.

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning The completed application must be mailed back.
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 5/22/2017

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