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Impax Patient Assistance Program
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PO Box 66554
St. Louis, MO 63166
Phone
:
877-764-9021
Fax:
877-764-9022
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Eligibility
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The Impax Patient Assistance Program provides brand name medications at no or low cost and is intended for patients that are uninsured or underinsured. Eligibility for patients with Medicare Part D will be determined on a case by case basis. Income requirements for this program have not been disclosed. Patients must be a US resident. |
| Who Can Apply
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Patients and doctors can apply by calling or downloading the application. |
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Required
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Patients and physician's must complete and sign the application. Proof of income must be faxed along with the application. Patient and physicians will be notified by mail withing 7-10 days. |
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Supply
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Supply varies. |
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Ship To
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Medication will be shipped to the patients home within 7-10 days. |
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Note
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Those with Medicare Part D must have spent at least 3% of annual household income out-of-pocket on prescription medicines.
Contact program for Spanish 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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| Rytary capsule; extended release |
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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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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
:
(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.
Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Note: All new enrollment is now done electronically or over the phone. Contact program for details. |
| |
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.
|
| Rytary capsule; extended release |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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