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Patient Assistance Information

 
 
 
Xubex Pharmaceutical Services

PO Box 1244
Winter Park, FL 32790-1244
Phone : 866-699-8239
Fax: 407-671-7960
Eligibility
> Patients may have insurance. There are no income limits for this program. Patients must be a US resident.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application.
Supply
> Varies
Ship To
> Either Doctor's office or Patient's home
Note
> No proof of income is required. Check the website for the exact price. This service is not currently available in Montana.
 
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.
 
Adipex-P (phentermine HCl)
Afeditab CR tablet; extended release
Alphagan P Solution
Alrex Suspension
Atripla tablet
AzaSite ophthalmic solution
Azopt Suspension
Belviq tablet
Bepreve ophthalmic solution
Betimol
BiDil tablet
Bystolic tablet
Calphron
Celebrex
Combigan
Complera
Cosopt PF ophthalmic solution/drops
Descovy
Divigel gel
Durezol ophthalmic emulsion
Dutoprol tablet; extended release
Edarbi tablet
Edarbyclor tablet
Emtriva capsule
Evekeo tablet
Evotaz
Evzio injectable; subcutaneous
Fetzima capsule; extended release
Genvoya tablet
Glycolax
Ilevro ophthalmic suspension/drops
Jantoven Tablets
Keppra (levetiracetam)
Kerydin solution
Lipitor Tablets
Lotemax Gel ophthalmic gel
Lotemax Ointment ophthalmic ointment
Lumigan Ophthalmic Solution
Minivelle transdermal system
Moxeza ophthalmic solution/drops
Odefsey
Prolensa ophthalmic solution/drops
Rescriptor Tablets
Restasis Ophthalmic Emulsion
Simbrinza ophthalmic suspension/drops
Stribild
Sulfazine
Tobradex ST ophthalmic suspension/drops
Toujeo Solostar injection
Travatan Z ophthalmic solution/drops
Truvada Tablets
Tybost
Ventolin HFA
Viagra Tablets
Videx (didanosine)
Vigamox ophthalmic solution/drops
Viramune
VIRAMUNE XR (nevirapine)
Viread
Vitekta tablet
Xalatan ophthalmic solution/drops
Zenzedi tablet
Zylet Ophthalmic Suspension
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader