Program Guidelines
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Important Information About Medicare Part D

The Forest Pharmaceuticals, Inc. (FPI), Patient Assistance Program provides medication for qualifying patients at no charge. If the patient qualifies under FPI guidelines, a three-month supply of the requested drug(s) or device(s) will be shipped to the patient’s licensed practitioner for dispensing to the patient.

  • Applying for the Program
    To apply for the program:
    • The patient and licensed practitioner must complete and sign the Patient Assistance Program application form, and the licensed practitioner must attach a prescription (Rx), for a three-month supply, for each drug or device being requested.


      • Note: If the delivery address on the Rx does not match the delivery or mailing address on the Patient Assistance Program application form, then the licensed practitioner must also attach letterhead or a business card to verify the delivery or mailing address.


  • Submittal Information
    Completed Patient Assistance Program application forms, along with the required prescriptions must be sent to the address at the top of the page.

    Note: Copies of a blank Patient Assistance Program application form may be made for future use. However, FPI WILL NOT ACCEPT faxes, emails, or copies of a completed application form.

  • Application Processing
    Please allow 4 weeks for application processing and delivery of medication.
    • If the patient is approved, a three-month supply of the drug(s) or device(s) requested will be sent via UPS to the licensed practitioner’s office for dispensing.

    • If the patient is denied, the licensed practitioner and patient will be notified by mail.

    • Unless stated otherwise, incomplete applications will be returned to the licensed practitioner or the patient with instructions for completion.


  • Applying for Refills
    Each time a qualifying patient’s prescription needs refilled; a new Patient Assistance Program application form and Rx must be submitted to FPI.
The following medications are available through the program:

Medication Strength Size
Aerobid® Inhaler N/A 7 gm canister
Aerobid® M Inhaler N/A 7 gm canister
* Aerochamber® N/A N/A
* Aerochamber® Mask N/A Sm, Reg, Lg
Armour® Thyroid Tablets ¼, ½, 1, 1 ½, 2, 3, 4, 5 gr 100 ct. bottle
Campral® Dose Pak 333 mg 180 ct.
Campral® Tablets 333 mg 180 ct. bottle
Celexa™ Tablets 10, 20, 40 mg 100 ct. bottle
Kay Ciel® Powder Packets N/A 100 ct. pack
Levothroid® Tablets 25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg 100 ct. bottle
Lexapro™ Tablets 10, 20 mg 100 ct. bottle
Namenda™ Titration Pak N/A 4 week therapy
Namenda™ Tablets 5, 10 mg 60 ct. bottle
Tessalon® Perles 100, 200 mg 100 ct. bottle
Theochron™ Tablets 100, 200, 300 mg 100 ct. bottle
Thyrolar® Tablets ¼, ½, 1, 2, 3 100 ct. bottle
Tiazac® Capsules 120, 180, 240, 300, 360, 420 mg 90 ct. bottle
* Maximum amount for Aerochamber® or Aerochamber® with mask is one per patient in a six-month period.
Controlled substances are not available on FPI's program.

Download Application [pdf]
Download Namenda Application [pdf]

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Download Application
Download Namenda Application

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