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Amitriptyline Patient Assistance Programs

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: 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 3. 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

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 11/15/2016

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Xubex Patient Assistance Program

(Program 2 of 3. Scroll down to see them all.)

Provided by: Xubex
PO Box 1244 Winter Park, Fl 32790-1244 TEL: 866-699-8239 ALT PHONE: 407-478-2663 FAX: 407-671-7960	Languages Spoken: English Program Website

Program Applications and Forms

Eligibility Requirements
Insurance Status	May have insurance
Those with Part D Eligible?	Yes, but contact program for details
Income	No limits
Diagnosis/Medical Criteria	Not specified
US Residency Required?	The patient must also be a US resident.

Application
Obtaining	Call or download
Receiving	Faxed, mailed or downloaded from website
Returning	The completed application can be faxed or mailed back.
Doctor's Action	Give prescription to patient
Applicant's Action	Complete section and sign
Decision Communicated	Not specified
Decision Timeframe	Not specified

Medication
Amount/Supply	Varies
Sent To	Doctor's office or patient's home
Delivery Time	Within 10 days
Refill Process	Automatically sent out
Limit	Varies per medication
Re-application	New application, new documentation yearly

Additional Information
No proof of income is required. Check the website for the exact price. This service is not currently available in Montana.
Updated 10/31/2016

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HealthWell Foundation Copay Program

(Program 3 of 3. 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

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 11/18/2016

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Amitriptyline Patient Assistance Programs

: Apply for prescription assistance below

Rx Outreach Medications

Provided by: Rx Outreach

Program Applications and Forms

Medications

Eligibility Requirements

Application

Medication

Additional Information

Xubex Patient Assistance Program

Provided by: Xubex

Program Applications and Forms

Medications

Eligibility Requirements

Application

Medication

Additional Information

HealthWell Foundation Copay Program

Provided by: HealthWell Foundation

Program Applications and Forms

HealthWell Foundation Copay Program: Contact program

Medications

Eligibility Requirements

Application

Medication

Additional Information