Patient Assistance Program

Welcome to the Forest Pharmaceuticals, Inc. Patient Assistance Program homepage. This program provides certain Forest products to patients who are unable to afford the cost of their medication and who meet other eligibility requirements. Eligibility for this program is based upon information you and your licensed practitioner provide on the application form. If you are approved, you will receive a three-month supply of the Forest product you require at no charge. Forest will ship your medication to your licensed practitioner's office for them to dispense to you.


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The following branded drugs and devices are available through
the Forest Pharmaceuticals, Inc. Patient Assistance Program
DRUG STRENGTH(S) SIZE
Armour® Thyroid
(thyroid tablets, USP) 		¼ gr, ½ gr, 1 gr, 1 ½ gr, 2 gr, 3 gr, 4 gr, 5 gr 100 ct. bottle
Bystolic® (nebivolol) Tablets 2.5 mg, 5 mg, 10 mg, 20 mg 100 ct. bottle
Campral® (acamprosate calcium)
Delayed-Release Tablets 		333 mg 180 ct. bottle
Daliresp® (roflumilast) Tablets 500 mcg 30 ct. bottle
Linzess™ (linaclotide) Capsules 145 mcg, 290 mcg 30 ct. bottle
Namenda® (memantine HCI) Tablets 5 mg, 10 mg 60 ct. bottle
Namenda® (memantine HCI)
Oral Solution 		10 mg = 5 mL 360 mL bottle
Namenda® (memantine HCI)
Titration Pak 		5 mg and 10mg combination pack 28 x 5 mg tablets;
21 x 10 mg tablets
Savella® (milnacipran HCI) Tablets 12.5 mg, 25 mg, 50 mg, 100 mg 60 ct. bottle
Savella® (milnacipran HCI HCI)
Titration Pack 		12.5 mg, 25 mg and 50 mg combination pack 5 x 12.5mg tablets;
8 x 25mg tablets; 42 x 50 mg tablets
Tudorza™ Pressair ™ (aclidinium
bromide inhalation powder) 		400 mcg 60 meter dose
Viibryd® (vilazodone HCI) Tablets 10 mg, 20 mg, 40 mg 30 ct. bottle
Viibryd® (vilazodone HCI)
Patient Starter Kit 		10 mg, 20 mg, and 40 mg combination pack 7 x 10 mg tablets; 7 x 20 mg
tablets; 16 x 40 mg tablets
DEVICE SIZE
AeroChamber-Plus® Flow-Vu
Mouthpiece* 		N/A N/A
AeroChamber-Plus® Flow-Vu Mask* N/A Small, Medium, Large

* Maximum amount for AeroChamber® or AeroChamber® with mask is one per applicant in a six-month period.

  Controlled substances and generic drugs and devices are not available through the Forest Pharmaceuticals, Inc.
  Patient Assistance Program.

  ARMOUR®, BYSTOLIC®, SAVELLA®, and VIIBRYD® are registered trademarks of Forest Laboratories, Inc.
  AEROCHAMBER®/ AEROCHAMBER PLUS® are registered trademark of Trudell Medical International.
  CAMPRAL® is a registered trademark of Merck Santé.
  DALIRESP® is a registered trademark of Nycomed GmbH.
  LINZESS™ is a registered trademark of Ironwood Pharmaceuticals, Inc.
  NAMENDA® is a registered trademark of Merz Pharma GmbH.
  TUDORZA™ and PRESSAIR™ are a registered trademark of Almirall, SA.


©2012 Forest Laboratories, Inc.  85-1021010 02/12

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  • 800-851-0758
    7:30 AM - 5:00 PM (CT),
    Monday - Friday
  • Fax# 1-636-754-0570

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