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      Patient Assistance Program Center

Program Details


Plaquenil (hydroxychloroquine tablet)
Address: RxOutreach
PO Box 66536
St. Louis, MO 63166-6536
Phone: 1-888-796-1234 Provider Phone:
Fax: Website:
Eligibility Info:
  • An individual of any age can participate in the program, as long as the program's financial guidelines are met.
  • Click here to enroll online.
  • COVID-19 Update:Rx Outreach has expanded the eligibility guidelines beyond 400% FPL to include people affected by COVID-19.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: No
    Social security requested on form: Yes
    US citizenship/residency specified: No
    Attachments Required: Prescription
    Also include check, money order or credit card information.
    Physician License #
    Not Required
    Prescriber Signature
    Only patient needs to sign the application.
    Application may be
    Eligibility determination
    letter sent:
    Receives: Medication
    Shipped To: Provider
    medications sent to wherever the patient requests it.
    Quantity in Shipment: 90-day supply
    Some medications have 180-day supplies available.
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    Refill Policy: Prescription can be written with refills for up to one year.
    Other Information:
  • A separate application must be submitted for each household member applying for medication. Only one application is required per patient; however, a doctor's prescription for each medication must accompany the application.
  • Administrative fees for medications vary. Please refer to the application for the appropriate fees.
  • Last Updated: 04/30/2020




    Application Forms
    & Instructions

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

    DocumentForm (English)

    Document Refill (English)


    Print-friendly version

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