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Wellspring Patient Assistance Program
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PO Box 801
Somerville, NJ 08876
Phone
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908-203-3791
Fax:
Not Applicable
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Eligibility
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The patient must have no prescription coverage for the medication, have reached his/her cap or the insurance company pays less than 25% of prescription costs and meet income guidelines that are not disclosed. |
Who Can Apply
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The doctor/doctor's office should call for an application. |
Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
Supply
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Up to a 90-day supply |
Ship To
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Doctor's office |
Note
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The doctor/doctor's office should call for an application. |
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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. |
Dibenzyline (phenoxybenzamine HCL) |
Dyrenium (triamterene) |
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