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Zubsolv Patient Assistance Program
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PO Box 219
Glouchester, MA 01931
Phone
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(888)236-4167
Fax:
(888)246-6527
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Eligibility
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This program provides brand name medications at no or low cost to patients that have no prescription coverage for the needed medication. Medicare Part D patients are eligible if the medication is not covered. Patients income must be at or below 300% of the federal poverty level. Patient must have an FDA-approved diagnosis and must be a US resident with a prescription from a US doctor. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed, emailed or mailed. An application can also be downloaded. |
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Required
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Doctors must complete a section of the application, sign and attach a prescription. Patients must complete a section of the application, sign and attach proof of income and a valid photo ID. Application can then be emailed, faxed or mailed. |
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Supply
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30 day supply |
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Ship To
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Patient's home, unless otherwise noted |
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Note
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This program also provides copay assistance: 1-888-982-7658 |
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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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| Zubsolv tablet; sublingual |
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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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