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Patient Assistance Information

1 Program for Relistor syringe; prefilled
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 syringe; prefilled
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader