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Rx Outreach Medications
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PO Box 66536
St Louis, MO 63166
Phone
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(888)796-1234
Fax:
(800)875-6591
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Eligibility
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Patients with insurance, including Medicare Part D, are eligible. Patients must be at or below 300% of the federal poverty level and reside in the US. |
| Who Can Apply
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Patients or healthcare providers can call to have an application mailed or faxed. It can also be downloaded. |
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Required
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Patients must complete a section and sign. Doctors must provide the patient with a prescription. The application can then be faxed and the prescription can be sent by E-Prescribe. |
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Supply
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Varies |
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Ship To
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Doctor's office or patient's home |
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Note
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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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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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| Dyrenium (triamterene) |
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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 |
| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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Wellspring Patient Assistance Program
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PO Box 801
Somerville, NJ 08876
Phone
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908-203-3791
Fax:
Not Applicable
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Eligibility
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The patient must have no prescription coverage for the medication, have reached his/her cap or the insurance company pays less than 25% of prescription costs and meet income guidelines that are not disclosed. |
| Who Can Apply
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The doctor/doctor's office should call for an application. |
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Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Up to a 90-day supply |
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Ship To
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Doctor's office |
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Note
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The doctor/doctor's office should call for an application. |
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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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| Dyrenium (triamterene) |
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