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Patient Assistance Program

Akrimax offers a patient assistance program providing Akrimax 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.




Eligible Medicines


  • Inderal® LA (propanolol hydrochloride) Long-Acting Capsules
  • Nitromist® (Nitroglycerin Lingual) Aerosol
  • Tirosint® (levothyroxine sodium) capsules
  • Suprenza (phentermine HCI) Orally Disintegrating Tablets
  • Primlev (Oxycodone HCI/Acetaminophen)
  • InnoPran XL® (propanolol hydrochloride) Extended Release Capsules



2014 Income Guidelines*

Household size including yourself12345678
Annual household income limit (Lower 48 states)$23,340$31,460$39,580$47,700$55,820$63,940$72,060$80,180
Annual household income limit (Alaska)$29,160$39,320$49,480$59,640$69,800$79,960$90,120$100,280
Annual household income limit (Hawaii)$26,840$36,180$45,520$54,860$64,200$73,540$82,880$92,220

*For households with more than 8 persons, add the following for each additional person: Lower 48 = $8,120, Alaska = $10,160, Hawaii = $9,340



 
01

Download
Enrollment Form


Download PDF

02

Complete
Enrollment Form

Remember to include your name &
date of birth on all attachments.

Be sure your application is complete.
Questions? Call (855) 856-6915

03

Return Form

Please include any applicable Akrimax
prescription(s) and income documentation.

By Mail:
Akrimax Patient Assistance Program
PO Box 1402
Morrisville, NC 27560

By Fax**: (919) 443-1483

**Faxed prescriptions will be accepted only when faxed directly from a prescriber's office to the program. Faxed prescriptions will not be accepted for Primlev or Suprenza. 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.




Refill Information


Once you are enrolled, ordering a refill is easy. Just call (855) 856-6915 up to 2 weeks before your supply of medicine runs out.



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