- Allow 4-6 weeks upon your return of the application for medication to arrive.
- Medication will be dispensed with a 90 or 180 day supply depending on manufacturer.
- Medication will ship directly to the doctors office.
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Let our trained staff collect and assemble the proper forms and applications to submit on your behalf. We handle all the paperwork and the filing. Our goal is to guide you through the application process and secure your approval.
Feel Good About Yourself.
Maintain A Healthy Lifestyle.
Application Checklist
Welcome! The following information will help you apply to our program. If you have any questions during the application process and would like more information, please call toll free 1-800-472-0031 and one of our technicians will assist you.
Important: All required credentials must be received in order to process the application. Incomplete applications will inquire further delays until all materials are collected.
When completing the application verify all information is accurate and your name appears exactly as it is written on your passport or government issued ID. It is also important to provide as much information as you can, including insurance documents if available.
Once your application is complete you will be notified on how the Prescription Assistance Program is able to assist you.
If you would like more information or help with the application process, please call toll free 1-800-472-0031
To be eligible for free medication through a pharmaceutical company, an individual must be 250% or below the federal poverty guideline without prescription insurance and must be a citizen or legal resident of the United States. Requirements may vary from company to company.
Apply Today!
Program Application
Requirements
To promote healthier living through advocacy, comprehensive resources and managed care by helping individuals in need obtain prescription medication.
Mission Statement
RX Outreach Program
What to Expect
Contact Information
Application
If you do not qualify for free medications and have an income under $45,180 as an individual you may qualify for our RX Outreach Program, which helps lower the cost of generic medication. If you take generic medication follow the link to see if the medication you are currently prescribed is distributed by the RX Outreach Program by typing the brand specific or generic equivalent into the search button on the RX Outreach Program medication page.
- List of Medication from Doctor's Office
- Income Verification - Acceptable forms include: most recent tax return Form 1040, Social Security Benefit Statement, Unemployment Statement or one-month of checks stubs.If you do not have an income please download the 4506-T Form.
- Copy of Photo ID, Social Security Card or Green Card.
- Copy of Health Insurance Cards if applicable.
- Printout showing current year's medication expenses. (Medicare D clients only).
Valley City Office:
139 2nd Avenue Southeast
Valley City, North Dakota 58072
Toll Free 800.472.0031 Fax 701.845.4073