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Rayos: Apply for prescription assistance below
If you are eligible, the programs below can help you afford Rayos. 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.
Horizon Patient Assistance Program
(Program 1 of 9. Scroll down to see them all.)
Provided by: Horizon Pharma USA, Inc. |
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PO Box 42886
Cincinnati, OH 45242
TEL: 866-247-2228 FAX: 513-338-8246 |
Languages Spoken: English Program Website |
Program Applications and Forms
Horizon Patient Assistance Program: Contact program
Medications |
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Eligibility Requirements |
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| Insurance Status |
Must have no prescription coverage
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| Those with Part D Eligible? | No | |
| Income | At or below 200% of FPL | |
| Diagnosis/Medical Criteria | Not specified | |
| US Residency Required? | Must reside and receive treatment in US | |
Application |
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| Obtaining | Call or enroll online | |
| Receiving | Faxed | |
| Returning | The completed application can be faxed back or submitted online | |
| Doctor's Action | Complete section and sign | |
| Applicant's Action | Complete section, sign and provide annual income information. Proof of income required | |
| Decision Communicated | Not specified | |
| Decision Timeframe | Not specified | |
Medication |
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| Amount/Supply | Up to 3 months supply | |
| Sent To | Doctor's office | |
| Delivery Time | Not specified | |
| Refill Process | Not specified | |
| Limit | One year | |
| Re-application | New application, new documentation yearly | |
Additional Information |
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| Updated 11/18/2016 |
Rx Outreach Medications
(Program 2 of 9. Scroll down to see them all.)
Provided by: Rx Outreach |
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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
Medications |
Eligibility Requirements |
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| Insurance Status |
May have insurance
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| 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 |
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| 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 |
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| 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 |
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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).
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| Updated 11/15/2016 |
Xubex Patient Assistance Program
(Program 3 of 9. Scroll down to see them all.)
Provided by: Xubex |
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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
Medications |
Eligibility Requirements |
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| Insurance Status |
May have insurance
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| 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 |
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| 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 |
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| 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 |
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No proof of income is required. Check the website for the exact price.
This service is not currently available in Montana.
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| Updated 10/31/2016 |
HealthWell Foundation Copay Program
(Program 4 of 9. Scroll down to see them all.)
Provided by: HealthWell Foundation |
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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 |
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Eligibility Requirements |
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| Insurance Status |
May have insurance
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| 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 |
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| 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 |
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| 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 |
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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.
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| Updated 11/18/2016 |
HealthWell Foundation Copay Program
(Program 5 of 9. Scroll down to see them all.)
Provided by: HealthWell Foundation |
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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 |
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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.
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| Updated 11/18/2016 |
HealthWell Foundation Copay Program
(Program 6 of 9. Scroll down to see them all.)
Provided by: HealthWell Foundation |
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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 11/18/2016 |
HealthWell Foundation Copay Program
(Program 7 of 9. Scroll down to see them all.)
Provided by: HealthWell Foundation |
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|
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.
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| Updated 11/18/2016 |
Patient Access Network Foundation (PAN)
(Program 8 of 9. Scroll down to see them all.)
Provided by: Patient Access Network Foundation |
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PO Box 221858
Charlotte, NC 28222-1858
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
- Patient Access Network Foundation (PAN) Patient Brochure (PDF)
- Patient Access Network Foundation (PAN) Provider Brochure (PDF)
Medications |
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Eligibility Requirements |
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| Insurance Status |
*See Additional Information section below
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| Those with Part D Eligible? | Determined case by case | |
| Income | Between 400-500% of FPL | |
| Diagnosis/Medical Criteria | Medically appropriate condition/diagnosis | |
| US Residency Required? | Must reside and receive treatment in US | |
Application |
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| 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 |
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| 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 |
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*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.
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| Updated 8/2/2016 |
Patient Access Network Foundation (PAN)
(Program 9 of 9. Scroll down to see them all.)
Provided by: Patient Access Network Foundation |
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PO Box 221858
Charlotte, NC 28222-1858
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
- Patient Access Network Foundation (PAN) Patient Brochure (PDF)
- Patient Access Network Foundation (PAN) Provider Brochure (PDF)
Medications |
|
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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 | Medically appropriate condition/diagnosis | |
| 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.
|
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| Updated 8/2/2016 |
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Home | About Online Pharmacies | Rogue Pharmacies | Testimonials | Save Money | Manage Price Alerts
En Español | News Releases | New Blog Post | Blog Archive | Join Free Newsletter
Verification Program | Other Services | Affiliate Program | Privacy Policy | Help/Contact Us
Copyright 2017, PharmacyChecker.com LLC. All rights reserved. PharmacyChecker.com is a registered service mark of PharmacyChecker.com, LLC.