IBSA offers a patient assistance program providing IBSA brand name medications to individuals who meet eligibility requirements. Eligibility is based on your annual household income and prescription insurance status. To see if you are eligible, complete and return the enrollment form. If you qualify, you will automatically be mailed your first 30-day supply. You will then be eligible to receive free medicine(s) for up to one year by calling to refill your prescription every month. You must re-enroll each year to remain in the program.
|Household size including yourself||1||2||3||4||5||6||7||8|
|Annual household income limit (Lower 48 states)||$24,280||$32,920||$41,560||$50,200||$58,840||$67,480||$76,120||$84,760|
|Annual household income limit (Alaska)||$30,360||$41,160||$51,960||$62,760||$73,560||$84,360||$95,160||$105,960|
|Annual household income limit (Hawaii)||$27,920||$37,860||$47,800||$57,740||$67,680||$77,620||$87,560||$97,500|
*For households with more than 8 persons, add the following for each additional person: Lower 48 = $4,320, Alaska = $5,400, Hawaii = $4,970
Remember to include your name
& date of birth on all attachments.
Be sure your application is
complete. Questions? Call:
Please include any applicable
prescription(s) and income documentation.
IBSA Patient Assistance Program
PO Box 32093 Charlotte, NC 28232
**Faxed prescriptions will be accepted only when faxed directly from a prescriber’s office to the program. Faxed prescriptions will not be accepted for Tirosint. The fax must include a cover page with the prescriber’s contact information, medical provider address, DEA number and patient name. Faxed prescriptions without this information will not be accepted and will be discarded.
Once you are enrolled, ordering a refill is easy. Just call (833) 838-3247 up to 2 weeks before your supply of medicine runs out.
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