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Program Details

FOREST PHARMACEUTICALS, INC
Patient Assistance Program

Viibryd tablets (vilazodone)
 
CONTACT INFO
Address: 13645 Shoreline Drive
St. Louis, MO 63045
Phone: 1-800-851-0758 Provider Phone:
Fax: 1-636-754-0570 Website: Forest PAP website
ELIGIBILITY
Eligibility Info:
  • Household income must fall below Forest Pharmaceuticals pre-determined income guidelines.
  • Patient can not have prescription drug coverage for medication requested.
  • 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
    APPLICATION
    Attachments Required: Prescription
    Physician License #
    Required:
    Both DEA and State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    No
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    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: 02/20/2014

     

     

     


    Application Forms
    & Instructions

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


    DocumentForm (English)


    Document Instructions (English)



     

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