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Program Details

Patient Assistance Program

Oxycontin CR (Oxycodone hcl controlled-release)
Address: c/o Express Scripts SDS
PO Box 66547
St. Louis, MO 63166-6547
Phone: 1-800-599-6070 Provider Phone:
Fax: Website: Program Website
Eligibility Info:
  • Patients must not have insurance coverage and must be ineligible for any state or federal programs.
  • Income at or below: Single 100 % FPL
      Couple 100 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    Attachments Required: Financial
    Proof of residency
    Physician License #
    Not Published
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: 30 days
    Delivery Time: 2-4 weeks
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    New prescription every 1 months
    Refill Policy: A new prescription is needed for each refill.
    Other Information: Company will only accept initiation of process from physicians office. If the patient is approved for the program, physician must write an original script each month for the patient.

    Last Updated: 09/15/2014




    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


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