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Patient Assistance Information

1 Program for Relistor injection
Salix Pharmaceuticals Patient Assistance Program

PO Box 66520
St. Louis, MO 63166-6520
Phone : 866-282-6563
Fax: 877-738-3694
> The patient must have no prescription coverage for any medications and have an income at or below 200% of the Federal Poverty Level. The patients must also have a medically appropriate diagnosis/condition and have a verifiable US or US territory address (no PO Box).
Who Can Apply
> The doctor or patient can call to request an application.
> The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income.
> 90 day supply with up to 3 refills, for a total of up to 1 year of medications
Ship To
> Patient's home
> May have Medicare Part D and Must be at or below 500% FPL for Fulyzaq and Xifaxan. Contact program for Spanish 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.
Relistor injection
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader