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Rx Outreach Medications

Summary:

Express Scripts, Inc. was founded in 1986 in St. Louis, Missouri. Express Scripts, Inc. is a licensed home delivery pharmacy. They provide their patients within the United State and Canada with their prescriptions through mail order at a reduced rate from standard pharmacies. Express Scripts, Inc. currently manages over 390 million retail prescriptions with a distribution of over 40 million prescriptions filled annually. They pride themselves at the level of safety and security their services offer their clients.

Express Scripts Specialty Distribution Services was launched in 2004 as a subsidiary of Express Scripts, Inc..

Eligibility:

Rx Outreach Medications, a patient assistance program provided by Express Scripts Specialty Distribution Services, offers the medications listed to the right at a fee of $20-$40 for up to 90 days to those who are eligible for the program. Eligibility is based off of the following requirements:

- Your income must be less than or equal to 300% of the Federal Poverty Guideline for the size of your household (see chart below).
SOURCE: 2008 HHS Poverty Guidelines
Persons in Family or Household 48 Contigous States and D.C. Alaska hawaii
1 $10,400 $13,000 $11,960
2 $14,000 $17,500 $16,100
3 $17,600 $22,000 $20,240
4 $21,200 $26,500 $24,380
5 $24,800 $31,000 $28,520
6 $28,400 $35,500 $32,660
7 $32,000 $40,000 $36,800
8 $35,600 $44,500 $40,940
For each addtional person, add $3,600 $4,500 $4,140

What’s Next?

Fill out the program enrollment form located to your right. If you don’t see an enrollment form available please call Express Scripts Specialty Distribution Services program directly. After filling out the enrollment form please bring the form to your doctor for proper signatures and procedures. Do not forget a self stamped envelope for them to mail in your application to the program.

Other Tips

  • If you have any questions please call the Express Scripts Specialty Distribution Services program directly
  • Fill out as much of the information on the enrollment form as possible. The more information you have pre-filled the easier the progrm is to enroll in
  • Write down the refill dates for your program and set a reminder here on PatientAssistance.com so that you don’t run out of medication.
  • Do not write messy on your forms as this will delay any response
  • Call and write thank you notes to Express Scripts Specialty Distribution Services program. Without their help millions of people will be without medication.




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    List of Medications:
    Acyclovir Tablets 400mg (Zovirax), Albuterol Inhaler 17 Gram (Proventil), Albuterol Inhaler 17gram (Ventolin), Allopurinol Tablets 100mg, 300mg (Zyloprim), Alprazolam Tablets 0.25mg, 0.5mg, 1mg, 2mg (Xanax), Amiodarone Tablets 200mg (Pacerone), Amitriptyline Tablets 10mg, 25mg, 50mg, 75mg, 100mg, 150mg (Elavil), Amlodipine Tablets 2.5mg, 5mg, 10mg (Norvasc), Atenolol Tablets 25mg, 50mg, 100mg (Tenormin), Atenolol/chlorthalidone Tablets 50/25mg, 100/25mg (Tenoretic), Belladonna Alkaloids/phenobartbital Tablets  (Donnatal), Benazepril Tablets 5mg, 10mg, 20mg, 40mg (Lotensin), Benazepril/hct Tablets 5mg/6.25mg, 10mg/6.25mg, 20mg/12.5mg, 20mg/25mg, 40mg (Lotensin HCT), Benztropine Tablets 0.5mg, 1mg, 2mg (Cogentin), Betamethasone Dipropionate Cream 0.05% (45gm) (Diprolene AF), Bisoprolol/hctz Tablets 2.5/6.25mg, 5/6.25mg, 10/6.25mg (Ziac), Bumetanide Tablets 0.5mg, 1mg, 2mg (Bumex), Bupropion Tablets 75mg, 100mg (Wellbutrin), Buspirone Tablets 5mg, 10mg, 15mg, 30mg (BuSpar), Butalbital/acetaminophen/caffeine Tablets 40mg, 50mg, 325mg (Esgic), Butalbital/acetaminophen/caffeine Tablets 40mg, 50mg, 325mg (Fioricet), Captopril Tablets 12.5mg, 25mg, 50mg, 100mg (Capoten), Carbamazepine Tablets 200mg (Tegretol), Carvedilol Tablets 3.125mg, 6.25mg, 12.5mg, 25mg (Coreg), Chlordiazepoxide/clidinium Capsules  (Librax), Cilostazol Tablets 50mg, 100mg (Pletal), Citalopram Tablets 10mg, 20mg, 40mg (Celexa), Clonazepam Tablets 0.5mg, 1mg, 2mg (Klonopin), Clonidine Tablets 0.1mg, 0.2mg (Catapres), Colchicine Tablets 0.6mg (Colchicine), Cyclobenzaprine Tablets 10mg (Flexeril), Diazepam Tablets 2mg, 5mg, 10mg (Valium), Diclofenac Tablets 25mg, 50mg, 75mg (Voltaren), Dicyclomine Capsule 10mg (Bentyl), Dicyclomine Tablets 20mg (Bentyl), Digoxin Tablets 0.125mg, 0.25mg (Lanoxin), Diltiazem Capsule 120mg, 180mg, 240mg (Dilacor XR), Diphenoxylate/atropine Tablets 2.5/0.025mg (Lomotil), Diphenoxylate/atropine Tablets 2.5/0.025mg (Lonox), Doxazosin Tablets 1mg, 2mg, 4mg, 8mg (Cardura), Doxepin Capsule 10mg, 25mg, 50mg, 75mg, 100mg (Sinequan), Enalapril Tablets 2.5mg, 5mg, 10mg, 20mg (Vasotec), Enalapril/hctz Tablets 5/12.5mg, 10/25mg (Vaseretic), Estradiol Tablets 0.5mg, 1mg, 2mg (Estrace), Estropipate Tablets 0.625/(0.75mg), 1.25/(1.5mg) (Ortho-Est), Estropipate Tablets 0.625mg, 1.25mg (Ogen), Ethinyl Estradiol/norgestimate Tablets 28days (Ortho Tri-Cyclen), Ethinyl Estradiol/norgestimate Tablets 28 Days (Ortho-Cyclen), Famotidine Tablets 20mg, 40mg (Pepcid), Finasteride Tablets 5mg (Proscar), Fluocinonide Topical Cream 0.05% (60gm) (Lidex), Fluoxetine Tablets 10mg, 20mg, 40mg (Prozac), Fluticasone Nasal Spray 50 Mcg (Flonase), Folic Acid Tablets 1mg (Folvite), Furosemide Tablets 20mg, 40mg, 80mg (Lasix), Gabapentin Capsules 100mg, 300mg, 400mg (Neurontin), Gemfibrozil Tablets 1mg (Lopid), Glimepiride Tablets 1mg, 2mg, 4mg (Amaryl), Glipizide Tablets 2.5mg, 5mg, 10mg (Glucotrol XL), Glipizide Tablets 5mg, 10mg (Glucotrol), Glyburide Tablets 1.5mg, 3mg, 6mg (Glynase PresTab), Glyburide Tablets 1.25mg, 2.5mg, 5mg (Micronase), Glyburide/metformin Tablets 1.25/250mg, 2.5/500mg, 5/500mg (Glucovance), Haloperidol Tablets 0.5mg, 1mg, 2mg, 5mg (Haldol), Hydrochlorothiazide Capsules 12.5mg (Microzide), Hydrochlorothiazide Tablets 25mg, 50mg (Esidrix), Hydrochlorothiazide Tablets 25mg, 50mg (HydroDIURIL), Hydrochlorothiazide Tablets 25mg, 50mg (Oretic), Hydrochlorothiazide/triamterene capsule 37.5/25mg, 75mg/50mg (Maxzide), Hydrochlorothiazide/triamterene Capsules 37.5mg/25mg (Dyazide), Hydrocortisone Rectal Suppository 25mg (Anucort-HC), Ibuprofen Tablets 400mg, 600mg, 800mg (Motrin), Indapamide Tablets 1.25mg, 2.5mg (Lozol), Isoniazid Tablets 300mg (Isoniazid), Isosorbide Mononitrate Tablets 10mg, 20mg (Ismo), Isosorbide Mononitrate Tablets 10mg, 20mg (Monoket), Isosorbide Mononitrate Tablets 30mg, 60mg, 120mg (Imdur), Labetalol Tablets 100mg, 200mg, 300mg (Trandate), Levothyroxine Tablets 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg 200mcg, 300mcg (Levoxyl), Levothyroxine Tablets 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg 200mcg, 300mcg (Synthroid), Lisinopril Tablets 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg (Prinivil), Lisinopril Tablets 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg (Zestril), Lisinopril/hctz Tablets 10/12.5mg, 20/12.5mg, 20/25mg (Prinzide), Lisinopril/hctz Tablets 10/12.5mg, 20/12.5mg, 20/25mg (Zestoretic), Lithium Capsules 300mg (Eskalith), Lorazepam Tablets 0.5mg, 1mg, 2mg (Ativan), Lovastatin Tablets 10mg, 20mg, 40mg (Mevacor), Meclizine Tablets 12.5mg, 25mg (Antivert), Medroxyprogesterone Tablets 2.5mg, 5mg, 10mg (Amen), Medroxyprogesterone Acetate Tablets 2.5mg, 5mg, 10mg (Provera), Meloxicam Tablets 7.5mg, 15mg (Mobic), Metformin Tablets 500mg, 850mg, 1000mg (Glucophage), Metformin Tablets 500mg, 750mg (Glucophage XR), Methotrexate Tablets 2.5mg (Methotrexate), Metoclopramide Tablets 5mg, 10mg (Reglan), Metolazone Tablets 2.5mg, 5mg (Zaroxolyn), Metoprolol Tablets 20mg, 25mg, 50mg, 100mg (Lopressor), Mirtazapine Tablets 15mg, 30mg, 45mg (Remeron), Nabumetone Tablets 500mg, 750mg (Relafen), Nadolol Tablets 20mg, 40mg, 80mg (Corgard), Naproxen Tablets 250mg, 375mg, 500mg (Naprosyn), Naproxen Sodium Tablets 550mg (Anaprox DS), Nitroglycerin Tablet Sublingual 0.4mg (Nitroquick), Nortriptyline Capsules 10mg, 25mg, 50mg, 75mg (Pamelor), Nystatin Cream 100, 000/unit/gm(30gm) (Mycostatin), Nystatin/triamcinolone Topical Cream 100, 000/unit/gm-0.1% (60gm) (Mycolog-II), Omeprazole Capsules 10mg, 20mg (Prilosec), Oxybutynin Tablets 5mg (Ditropan), Paroxetine Tablets 10mg, 20mg, 30mg, 40mg (Paxil), Pentoxifylline Tablets 400mg (Trental), Phenytoin Capsules 100mg (Dilantin), Piroxicam Capsules 10mg, 20mg (Feldene), Potassium Chloride Tablets  (K-Dur), Potassium Chloride Tablets 750mg (10meq) (Potassium Chloride ER), Pravastatin Tablets 10mg, 20mg, 40mg (Pravachol), Prednisone Tablets 1mg, 2.5mg, 5mg, 10mg, 20mg, 50mg (Deltasone), Prochlorperazine Maleate Tablets 5mg, 10mg (Compazine), Propafenone Tablets 150mg, 225mg, 300mg (Rythmol), Propranolol Tablets 10mg, 20mg, 40mg, 80mg (Inderal), Propylthiouracil Tablets 50mg (Propylthiouracil), Quinapril Tablets 5mg, 10mg, 20mg, 40mg (Accupril), Quinine Sulfate capsules 324mg (Qualaquin), Ranitidine Tablets 150mg, 300mg (Zantac), Sertraline Tablets 25mg, 50mg, 100mg (Zoloft), Simvastatin Tablets 5mg, 10mg, 20mg, 40mg, 80mg (Zocor), Spironolactone Tablets 25mg (Aldactone), Tamoxifen Tablets 10mg, 20mg (Nolvadex), Temazepam Capsule 15mg, 30mg (Restoril), Terazosin Capsules 1mg, 2mg, 5mg, 10mg (Hytrin), Theophylline Tablets 100mg, 200mg, 300mg (Theo-Dur), Ticlopidine Tablets 250mg (Ticlid), Timolol Ophthalmic Ophthalmic Solution 0.5%, 0.25% (Timoptic), Tizanidine Tablets 2mg, 4mg (Zanaflex), Tramadol Tablets 50mg (Ultram), Trazodone Tablets 50mg, 100mg, 150mg, 300mg (Desyrel), Triamcinolone Topical Cream 0.1% (80gm) (Aristocort A), Triamcinolone Topical Cream 0.1% (80gm) (Kenalog), Trimethoprim/sulfamethoxazole Tablets  (Bactrim DS), Trimethoprim/sulfamethoxazole Tablets  (Septra DS), Verapamil Tablets 40mg, 80mg, 120mg (Calan), Verapamil Tablets 40mg, 80mg, 120mg (Isoptin), Verapamil Tablets 40mg, 80mg, 120mg (Isoptin SR), Verapamil Tablets 12mg, 18mg, 24mg (Calan SR), Warfarin Tablets 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg (Coumadin), Zolpidem Tablets 5mg, 10mg (Ambien)

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