Find out if you may be eligible

This free prescription program is available to individuals who meet certain income requirements, don’t have insurance coverage, are being treated as an outpatient by a United States licensed doctor, and live in the United States or a U.S. Territory.

To find out if you may be eligible, just answer a few simple questions or view our eligibility requirements.

Step 1

Please select a medicine.

The information you enter will not be saved or used in any way. This is meant as guidance only.

Step 2

Please select a number from the dropdown.

Step 3

Please select an income from the dropdown.

Different medicines have different income eligibility requirements.

Step 4

Answer the following questions (required)

Please select an answer for all questions.

Please answer all questions above to submit this form.

Cancel SUBMIT

Based on what you told us,

we encourge you to apply.

Apply Today

we may be able to help but
need more information.

Call 1-800-652-6227

It appears that you’re not eligible for the program because:

If you wish to speak to someone or have any questions about your eligibility, please call our program at

1-800-652-6227

Medication

Family Size

Family Income

Do you live in the United States or a United States Territory?

Are you being treated by a United States licensed doctor?

Are you being treated as an outpatient?

Do you have any insurance or Medicare/Medicaid coverage?