• 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).
  • 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.
  • We also help with refills if you let us know when you are getting low.

What to Expect

Requirements

Contact Information

​​If you do not qualify for free medications and have an income under $36,180 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.


To be eligible for free medication through a Pharmaceutical companies prescription assistance program an individual must be below Federal Poverty Guideline without insurance. An individual with an income of $36,180 a year would be 300% of the Federal Poverty Line. 

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.

Program Application

Valley City Office:

139 2nd Avenue Southeast

Valley City, North Dakota 58072


     Toll Free 800.472.0031    Fax 701.845.4073     

Apply Today!

>>> APPLY

RX Outreach Program

.

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. 



Application Checklist

Application

Feel Good About Yourself.
                      
Maintain A Healthy Lifestyle.


Mission Statement

If you would like more information or help with the application process, please call toll free 1-800-472-0031


Hours: Mon - Fri    8:30am - 4:30pm


To promote healthier living through advocacy, comprehensive resources and managed care by helping individuals in need obtain prescription medication.