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Patient Assistance Information

 
2 Programs for Dyrenium (triamterene)
 
 
Rx Outreach Medications

PO Box 66536
St Louis, MO 63166
Phone : (888)796-1234
Fax: (800)875-6591
Eligibility
> 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
> Patients or healthcare providers can call to have an application mailed or faxed. It can also be downloaded.
Required
> 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.
Supply
> Varies
Ship To
> Doctor's office or patient's home
Note
> 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).
 
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.
 
Dyrenium (triamterene)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader
 
 
Wellspring Patient Assistance Program

PO Box 801
Somerville, NJ 08876
Phone : 908-203-3791
Fax: Not Applicable
Eligibility
> 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
> The doctor/doctor's office should call for an application.
Required
> 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.
Supply
> Up to a 90-day supply
Ship To
> Doctor's office
Note
> The doctor/doctor's office should call for an application.
 
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.
 
Dyrenium (triamterene)