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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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| Dibenzyline (phenoxybenzamine HCL) |
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