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Patient Assistance Information

 
1 Program for Dibenzyline (phenoxybenzamine HCL)
 
 
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.
 
Dibenzyline (phenoxybenzamine HCL)