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      Patient Assistance Program Center

Program Details

Patient Assistance Program

Savella (milnacipran HCl tablets)
Address: P.O. Box 66764
St. Louis, MO 63166
Phone: 1-800-851-0758 Provider Phone:
Fax: 1-844-708-0036 Website: Program Website
Eligibility Info:
  • Household income must fall below pre-determined income guidelines.
  • Patient can not have prescription drug coverage for medication requested.
  • Patients with Medicare Part D may be eligible, but must have been denied or are ineligible for Low Income Subsidy.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Not Published
    Attachments Required: Prescription
    Physician License #
    Both DEA and State
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Both Provider and Patient
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: 90 days
    Delivery Time: 2-4 weeks
    Re-application Policy: New application every 3 months
    New prescription every 3 months
    Refill Policy: A new form and prescription must be submitted each time a patient needs a refill.
    Other Information:

    Last Updated: 11/06/2015




    Application Forms
    & Instructions

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

    DocumentForm (English)


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