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Xubex Pharmaceutical Services
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PO Box 1244
Winter Park, FL 32790-1244
Phone
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866-699-8239
Fax:
407-671-7960
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Eligibility
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Patients may have insurance. There are no income limits for this program. Patients must be a US resident. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application. |
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Supply
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Varies |
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Ship To
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Either Doctor's office or Patient's home |
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Note
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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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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Adipex-P (phentermine HCl) |
| Afeditab CR tablet; extended release |
| Alphagan P Solution |
| ALREX® (loteprednol etabonate ophthalmic suspension) |
| Atripla tablet |
| AzaSite ophthalmic solution |
| Azopt Suspension |
| Belviq tablet |
| Bepreve ophthalmic solution |
| Betimol |
| BiDil tablet |
| Bystolic tablet |
| Calphron |
| Celebrex |
| Combigan |
| Complera |
| Cosopt PF ophthalmic solution/drops |
| Descovy |
| Divigel gel |
| Durezol ophthalmic emulsion |
| Dutoprol tablet; extended release |
| Edarbi tablet |
| Edarbyclor tablet |
| Emtriva capsule |
| Evekeo tablet |
| Evotaz |
| Evzio injectable; subcutaneous |
| Fetzima capsule; extended release |
| Genvoya tablet |
| Glycolax |
| Ilevro ophthalmic suspension/drops |
| Jantoven Tablets |
| Keppra (levetiracetam) |
| Kerydin solution |
| Lipitor Tablets |
| Lotemax Gel ophthalmic gel |
| Lotemax Ointment ophthalmic ointment |
| Lumigan Ophthalmic Solution |
| Minivelle transdermal system |
| Moxeza ophthalmic solution/drops |
| Odefsey |
| Prolensa ophthalmic solution/drops |
| Rescriptor Tablets |
| Restasis Ophthalmic Emulsion |
| Simbrinza ophthalmic suspension/drops |
| Stribild |
| Sulfazine |
| Tobradex ST ophthalmic suspension/drops |
| Toujeo Solostar injection |
| Travatan Z ophthalmic solution/drops |
| Truvada Tablets |
| Tybost |
| Ventolin HFA |
| Viagra Tablets |
| Videx (didanosine) |
| Vigamox ophthalmic solution/drops |
| Viramune |
| VIRAMUNE XR (nevirapine) |
| Viread |
| Vitekta tablet |
| Xalatan ophthalmic solution/drops |
| Zenzedi tablet |
| ZYLET® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
(Requires Acrobat Reader) 
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