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PO Box 230999
Centerville, VA 20120
Phone : 800-545-6962
Fax: 703-310-2534
Eligibility
> The patient cannot have prescription insurance, be ineligible for any federal or state programs and meet income guidelines that are not disclosed. The patient must also be a US resident. Patients who are eligible for any government program, including Part D, are not eligible for this program. Patients must also be under the age of 65.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> 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.
Supply
> Up to a 120-day supply
Ship To
> Doctor's office
Note
> A refill/reorder form is included with each shipment that must be filled out and returned to get the next shipment. Once a year a new application with financial documentation is needed.
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.
Cymbalta
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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