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Zonisamide Patient Assistance Programs

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Zonegran: Apply for prescription assistance below


If you are eligible, the programs below can help you afford Zonegran. 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


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
  • Zonegran (zonisamide)

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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If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for Zonegran prices here.


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