Registered Users Log-in:

E-mail Address:


Forgot Password?
Patient Assistance Information

1 Program for Tri-Sprintec tablet
Rx Outreach Medications

PO Box 66536
St Louis, MO 63166
Phone : (888)796-1234
Fax: (800)875-6591
> 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.
> 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.
> Varies
Ship To
> Doctor's office or patient's home
> 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.
Tri-Sprintec tablet
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