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Patient Assistance Information

 
 
 
Zubsolv Patient Assistance Program

PO Box 219
Glouchester, MA 01931
Phone : (888)236-4167
Fax: (888)246-6527
Eligibility
> This program provides brand name medications at no or low cost to patients that have no prescription coverage for the needed medication. Medicare Part D patients are eligible if the medication is not covered. Patients income must be at or below 300% of the federal poverty level. Patient must have an FDA-approved diagnosis and must be a US resident with a prescription from a US doctor.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed, emailed or mailed. An application can also be downloaded.
Required
> Doctors must complete a section of the application, sign and attach a prescription. Patients must complete a section of the application, sign and attach proof of income and a valid photo ID. Application can then be emailed, faxed or mailed.
Supply
> 30 day supply
Ship To
> Patient's home, unless otherwise noted
Note
> This program also provides copay assistance: 1-888-982-7658
 
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.
 
Zubsolv tablet; sublingual
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader