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Patient Assistance Information

 
1 Program for Folgard OS
 
 
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.
 
Folgard OS
 
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