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INSTRUCTIONS FOR REFILLS and NEW PRESCRIPTIONS
Refills Online (You need a credit card to order online) Visit www.rxoutreach.org; sign in, your account activity will appear and those
prescriptions available for refill will be listed under the Prescription Category. Check the refill box on those prescriptions you wish to refill
and follow the remaining steps to complete you order.
Refills by Phone (You need a credit card to order by phone) - Call 1-888-RXO-1234 (796-1234) from 7:00 am to 5:30 pm CT Monday Friday to place an order or use our automated system by calling 1-888-RXO-1234 24 hours a day/7 days a week
Refills by Mail - Complete Sections A, B, and C below and mail the form and your payment to Rx Outreach
New Prescriptions by Mail - Complete Sections B and C below and mail the form, your prescription, and payment to Rx Outreach
To order controlled substances (CS), you must attach a copy of your photo ID card (for example, a driver’s license or state ID card) and a copy of
your Social Security Card or Green Card. Controlled Substances will be shipped separately from other medications. CONTROLLED
SUBSTANCES CAN NOT BE SHIPPED TO A PO BOX OR DOCTOR’S OFFICE. YOUR SHIPPING ADDRESS MUST BE A DELIVERABLE U.S.
POSTAL SERVICE STREET ADDRESS. Controlled substance medications are only allowed up to a maximum of a 90-day (3 months) supply. If a doctor
authorizes enough doses to be filled over 5 months (maximum allowed by law), the prescription is allowed 1 refill of a 90-day supply.
Enrolling in Rx Outreach for the first time…
Please complete the following information as well as the information in Sections B and C. Mail this form, your prescription(s), and
payment to Rx Outreach.
I attest that my income is at or below 300% of the federal poverty level. Annual income $___________ # in Household ______. I will not seek
reimbursement of any fee I pay to Rx Outreach from my health insurance, including Medicaid, Medicare, or similar programs.
Section A: Refills by Mail (use an additional sheet of paper if necessary)
Please fill in the below section for refills by mail. Mark whether you would like a 90-day or 180-day supply for each medication listed.
Not all medications are available in a 180-day supply (please refer to the enclosed drug list). If necessary, we may contact you or your
doctor for additional information.
Rx Number __________Product Name ___________________________
Rx Number __________Product Name ___________________________
Rx Number __________Product Name ___________________________
Rx Number __________Product Name ___________________________
Rx Number __________Product Name ___________________________
Rx Number __________Product Name ___________________________
90-day:
90-day:
90-day:
90-day:
90-day:
90-day:
___
___
___
___
___
___
180-day: ___
180-day: ___
180-day: ___
180-day: ___
180-day: ___
180-day: ___
Total
$__________ Administrative Fee
$__________ Administrative Fee
$__________ Administrative Fee
$__________ Administrative Fee
$__________ Administrative Fee
$__________ Administrative Fee
$__________
Section B: Patient Information
Soc Sec# / Green Card #/ or Rx Outreach #___________________________________ Date of Birth (MM/DD/YY) __ __/__ __/__ __
Last Name__________________________________________ First Name ______________________MI ______________________
Shipping Address ________________________________________________Apt #_____ Home Phone: _________________________
City ____________________________________________________________________ State _________ Zip Code: ______________
E-mail address: ________________________________________________________ Check this □ box if you would like to receive our newsletter.
Doctor’s Name _______________________________________Dr. Phone #____________________Dr. Fax #____________________
Please list any food/medicines you are allergic to: _____________________________________________________________________
Please list all medicines you are currently taking and medical conditions: __________________________________________________
Section C: Payment Information - personal check, money order, credit card (Visa, MasterCard, Discover, or FSA account only)
By check or money order: Make payable to Rx Outreach. (Please do not send cash) Amount Enclosed: $________
By credit card: Credit Card Number:
___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___
Check type of credit card you are using:
□ Visa □ MasterCard □ Discover □ FSA
Exp.: ______- ______
Credit (check one)
Debit
Total Amount $_______
I authorize Rx Outreach to charge this credit card for payment.
Name on card: ______________________________ Signature of cardholder: ______________________________________________
 I acknowledge that the information on this form is true and correct.
I consent to the release by my health care providers of my medication information
pertaining to prescriptions for Rx Outreach to be used for program authorization purposes.
Mail this form & payment to:
Rx Outreach / PO Box 66536 / St. Louis, MO 63166-6536
©2015 Rx Outreach. All Rights Reserved. Rev 04/15
RFRXO-0415
Rx Outreach Medication
AcipHex®
Acyclovir
Alendronate (1/week dosage)
Allopurinol
Alprazolam (CS)
Amitriptyline
Amlodipine
Aricept®
Atenolol
Atorvastatin
Azathioprine
Baclofen
Bicalutamide
Brimonidine Tartrate Solution
Budesonide nasal spray
Bupropion HCL
Bupropion HCL
Bupropion HCL SR
Bupropion HCL XL
Buspirone
Buspirone
Candesartan Cilexetil
Candesartan Cilexetil
Candesartan Cilexetil-HCTZ
Candesartan Cilexetil-HCTZ
Carbidopa / Levodopa SR
Carbidopa / Levodopa
Carvedilol
Celecoxib
Celecoxib
Celecoxib
Cilostazol
Citalopram
Clonazepam (CS)
Clonazepam (CS)
Clonidine HCL
Clopidogrel
Cyclobenzaprine
Diazepam (CS)
Diclofenac EC
Digoxin
Digoxin
Diltiazem ER (Dilt-CD)
Diphenoxylate/Atropine (CS)
Divalproex NA DR
Divalproex Sod ER
Divalproex Sod ER
Dorzolamide HCl 2% Solution
Dorzolamide/Timolol Solution
Doxazosin Mesylate
Duloxetine HCL DR
Enalapril Maleate
Escitalopram
Estradiol
Eszopiclone (CS)
Etodolac
Famotidine
Fenofibrate
Fenofibrate
Fenofibrate, micronized
Finasteride
Flecainide Acetate
Fluconazole
Fluoxetine
Fluticasone nasal spray
Folic Acid
Furosemide
Gabapentin capsule
Gabapentin tablet
Gemfibrozil
Glimepiride
Glipizide ER
Glipizide
Glyburide/Metformin
Glyburide
Hydralazine
Hydrochlorothiazide
Hydrocortisone
Hydrocortisone
Hydroxychloroquine
Hydroxyurea
Hydroxyzine pamoate or HCL
Ibuprofen
Ipratropium/Albuterol Solution
Irbesartan
Irbesartan/HCTZ
Isosorbide Mononitrate ER
Isosorbide Mononitrate
Labetalol HCL
Lamotrigine
Latanoprost 0.005% Solution
Leflunomide
Letrozole
Available Strengths
20mg
200mg cap, 400mg tab, 800mg tab
70mg (limit: 12 for 90; 24 for 180)
100mg, 300mg
0.25mg, 0.5mg, 1mg, 2mg
mg: 10, 25, 50, 75, 100, 150
2.5mg, 5mg, 10mg
5mg, 10mg
25mg, 50mg, 100mg
10mg, 20mg, 40 mg, 80mg
50mg
10mg, 20mg
50mg
0.2%/10ml dropper
8.6g/32mcg
75mg
100mg
100mg, 150mg, 200mg
150mg, 300mg
5mg, 10mg, 15mg
30mg
4mg, 8mg, 16mg
32mg
16/12.5mg
32/12.5mg, 32/25mg
25/100mg, 50/200mg
10/100mg, 25/100mg, 25/250mg
3.125mg, 6.25mg, 12.5mg, 25mg
50mg, 100mg
200mg
400mg
50mg, 100mg
10mg, 20mg, 40mg
0.5mg
1mg, 2mg
0.1mg, 0.2mg, 0.3mg
75mg
5mg, 10mg
2mg, 5mg, 10mg
50mg, 75mg
0.125mg
0.25mg
120mg, 180mg, 240mg, 300mg
2.5/0.025mg
125mg, 250mg, 500mg
250mg
500mg
10ml dropper
2%/0.5% 10ml dropper
1mg, 2mg, 4mg, 8mg
20mg, 30mg, 60mg
2.5mg, 5mg, 10mg, 20mg
5mg, 10mg, 20mg
0.5mg, 1mg, 2 mg
1mg, 2mg, 3mg
200mg, 300mg cap; 400mg, 500mg tab
20mg, 40mg
48mg, 54mg, 160mg
145mg
134mg
5mg
100mg, 150mg
100mg, 200mg
10mg, 20mg, 40mg
50mcg
1mg
20mg, 40mg, 80mg
100mg, 300mg, 400mg
600mg, 800mg
600mg
1mg, 2mg, 4mg
2.5mg, 5mg, 10mg
5mg, 10mg
1.25/250mg, 2.5/500mg, 5/500mg
1.25mg, 2.5mg, 5mg
10mg, 25mg, 50mg
12.5mg cap, 25mg tab, 50mg tab
5mg
10mg
200mg
500mg
25mg, 50mg
400mg, 600mg, 800mg
0.5mg/3.0mg vial
75mg, 150mg, 300mg
150mg/12.5mg, 300mg/12.5mg
30mg, 60mg 120mg
10mg, 20mg
100mg, 200mg, 300mg
25mg, 100mg, 150mg, 200mg
2.5ml dropper
10mg, 20mg
2.5mg
90-Day
180-Day
$35
$55
n/a
$20
$25
$45
n/a
$20
$9 up to 90 tabs
n/a
$20
n/a
$20
$40
$15
n/a
$9
$18
$25
$45
$20 for up to 90 tablets
$15
n/a
$35
$65
$15 per dropper
$62 per nasal spray
$40
n/a
$40 up to 90 tabs
n/a
$65
n/a
$65
n/a
$20
n/a
$35
n/a
$30 for up to 30 tablets
$40 for up to 30 tablets
$35 for up to 90 tablets
$45 for up to 90 tablets
$45
$85
$45
$85
n/a
$20
$25 for up to 30 capsules
$50 for up to 30 capsules
$75 for up to 30 capsules
$30
$55
$20
n/a
$9 up to 90 tabs
n/a
$10 up to 90 tabs
n/a
n/a
$20
$20 up to 90 tablets
$25
n/a
$8 up to 90 tabs
n/a
$25
n/a
$45 for up to 90 tablets
$20
n/a
$40 up to 90 capsules
$35
n/a
$35
$65
$65 for up to 90 tablets
$95 for up to 90 tablets
$15 per dropper
$15 per dropper
$35 for up to 90 tablets
$65
N/A
n/a
$20
$20
n/a
n/a
$20
N/A
$40 up to 90 tabs
$40 up to 90
n/a
n/a
$20
$55
$95
$55 for up to 30 tablets
$70
n/a
$25
$45
$35 for up to 90 tablets
$35 up to 30 tabs
$15
n/a
$15 per nasal spray
n/a
$20
$9
$18
$25 up to 270 capsules
$45 up to 270 tablets
$30
$55
n/a
$20
$35
$65
n/a
$20
$30
$55
n/a
$20
$25
$45
n/a
$20
$15 for up to 90 tablets
$25 for up to 90 tablets
$22 for up to 30 tablets
n/a
$25 up to 90 caps
$25
n/a
$20
n/a
$25 for up to 90 vials
$30
$55
$30
$55
n/a
$20
n/a
$20
$30 up to 90 tabs
n/a
$30
$55
$45 (limit 3)
n/a
$50
n/a
$30
$55
Rx Outreach Medication
Levetiracetam
Levetiracetam
Levetiracetam ER
Levothyroxine
Lisinopril/HCTZ
Lisinopril
Lithium Carbonate
Lithium Carbonate ER
Lorazepam (CS)
Lorazepam (CS)
Losartan Potassium
Losartan/HCTZ
Lovastatin
Meloxicam
Metformin HCL ER
Metformin HCL
Methotrexate
Metoprolol Succinate ER
Metoprolol Succinate ER
Metoprolol Tartrate
Mirtazapine
Modafinil (CS)
Montelukast Sodium
Mycophenolate Mofetil
Nabumetone
Naproxen Sodium
Naproxen
Nifedipine ER
Nortriptyline HCL
Omeprazole
Ondansetron/Ondansetron ODT
Ondansetron/Ondansetron ODT
Oxcarbazepine
Oxybutynin
Oxybutynin Chloride ER
Olanzapine
Olanzapine
Pacerone® (Amiodarone)
Pantoprazole
Paroxetine HCL
Pentoxifylline ER
Phenytoin Sodium
Pioglitazone HCL
Potassium Chloride powder
Potassium Chloride ER
Potassium Citrate
Pramipexole
Pravastatin
Prednisone
ProAir® HFA
Propranolol
Propranolol HCL ER
Quetiapine Fumarate
Quetiapine Fumarate
Quetiapine Fumarate
Quinapril
Ramipril
Ranitidine
Risperidone
Ropinirole HCL
Sertraline
Simvastatin
Spironolactone
Sumatriptan Succinate
Sumatriptan Succinate
Sumatriptan Succinate
Tacrolimus
Tacrolimus
Tamoxifen Citrate
Tamsulosin
Telmisartan
Temazepam (CS)
Theophylline ER
Tizanidine HCL
Topiramate
Tramadol (CS)
Trazodone
Trazodone
Triamterene/HCTZ
Valacyclovir HCl
Valacyclovir HCl
Valsartan
Valsartan
Valsartan/HCTZ
Venlafaxine
Venlafaxine ER
Verapamil SR
Verapamil
Warfarin
Ziprasidone
Zolpidem Tartrate (CS)
Zolpidem ER (CS)
Zonisamide
Available Strengths
250mg, 500mg 750mg
1000mg
500mg, 750mg
mcg: 25/50/75/88/100/112/125/137/150/175/200/300
10/12.5mg, 20/12.5mg, 20/25mg
mg: 2.5, 5, 10, 20, 30, 40
300mg
300mg, 450mg
0.5mg
1mg, 2mg
25mg, 50mg, 100mg
50/12.5mg, 100/12.5mg, 100/25mg
10mg, 20mg, 40mg
7.5mg, 15mg
500mg, 750mg
500mg, 850mg, 1000mg
2.5mg
25mg, 50mg, 100mg
200mg
25mg, 50mg, 100mg
15mg, 30mg, 45mg
100mg, 200mg
10mg, 5mg chewable
250mg Cap, 500mg Tab
500mg, 750mg
550mg
250mg, 375mg, 500mg
30mg, 60mg
10mg, 25mg, 50mg, 75mg
10mg, 20mg, 40mg
4mg
8mg
150mg, 300mg, 600mg
5mg
5mg, 10mg, 15mg
2.5mg, 5mg, 7.5mg, 10mg
15mg, 20mg
100mg, 200mg, 400mg
20mg, 40mg
10mg, 20mg, 30mg, 40mg
400mg
100mg
15mg, 30mg, 45mg
20mEQ, 25mEQ
8mEQ, 10mEQ, 20mEQ
5mEQ, 10mEQ
0.125mg, 0.25mg, 0.5mg, 1mg, 1.5mg
10mg, 20mg, 40mg, 80mg
mg: 1, 2.5, 5, 10, 20, 50
8.5g (200 actuations)
10mg, 20mg, 40mg, 80mg
60mg, 80mg, 120mg, 160mg
25mg, 50mg, 100mg
200mg, 300mg
400mg
5mg, 10mg, 20mg, 40mg
1.25mg, 2.5mg, 5mg, 10mg
150mg, 300mg
mg: 0.25, 0.5, 1, 2, 3, 4
0.25mg, 0.5mg, 1mg, 2mg
25mg, 50mg, 100mg
5mg, 10mg, 20mg, 40mg, 80mg
25mg
25mg
50mg
100mg
0.5mg
1mg
10mg, 20mg
0.4mg
20mg, 40mg, 80mg
15mg, 30mg
100mg, 200mg, 300mg
2mg, 4mg
25mg, 50mg, 100mg, 200mg
50mg
50mg
100mg, 150mg
Cap: 37.5/25mg - Tab: 37.5/25mg, 75/50mg
500mg
1gm
40mg, 80mg
160mg, 320mg
mg: 80/12.5, 160/12.5, 160/25, 320/12.5. 320/25
mg: 25, 37.5, 50, 75, 100
37.5mg, 75mg, 150mg
120mg, 180mg, 240mg
40mg, 80mg, 120mg
mg: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10
20mg, 40mg, 60mg, 80mg
5mg, 10mg
6.25mg, 12.5mg
25mg, 50mg, 100mg
90-Day
180-Day
$50
$95
$20 for up to 90 tablets
$80 up to 180 tablets
n/a
$20
$9
$18
$9
$18
$10 up to 270 caps
n/a
$35
n/a
$25
n/a
$30
n/a
$25
$45
$25
$45
$9
$18
$20
n/a
n/a
$20
n/a
$20
$20 per 12 tabs
n/a
$35
$65
$45
$85
n/a
$20
$30
n/a
$80
n/a
$40 up to 90 tablets
$65 up to 180 units
$40
n/a
$25
n/a
$20
n/a
$50
$95
$20
n/a
$35
$65
$50 up to 135 tabs
n/a
$50 up to 90 tabs
n/a
$60
n/a
n/a
$20
$45
$85
$25 up to 90 tabs
n/a
$50 up to 90 tabs
n/a
$25
$45
$20
n/a
$20
n/a
$30
$55
$20 up to 180 capsules
$25
n/a
$40 up to 90 packets
$25 up to 90 tablets
$15 up to 90 tablets
$25 up to 180 tablets
$25 up to 90 tablets
$20
n/a
$35 per canister
n/a
$20
$45 for up to 90 capsules
$25 up to 90 tabs
n/a
$40 up to 90 tabs
n/a
$50 up to 90 tabs
n/a
$30
$55
$25
$45
n/a
$20
$45
n/a
$45
$85
$25
n/a
$25
$45
n/a
$20
$35 up to 72 tabs
n/a
$35 up to 54 tabs
n/a
$35 up to 27 tabs
n/a
$60 for up to 90 capsules
$75 for up to 90 capsules
$25
$45
$30
$55
$35
$65
$16 up to 90 caps
n/a
$20 up to 90 tablets
$55
n/a
$35
$65
$7 up to 90 tabs
n/a
$12
n/a
$14
n/a
n/a
$20
$50 for up to 90 tablets
$75 for up to 90 tablets
$30 for up to 90 tablets
$40 for up to 90 tablets
$35
$65
$45
n/a
$45
n/a
$35
$65
n/a
$20
$25
n/a
$65 for 90 caps
n/a
$30
n/a
$45 up to 30 tabs
n/a
$20 up to 90 capsules
(CS) Controlled Substance
All prescriptions are evaluated by a pharmacist before being filled. The quantity may be limited based on dose restrictions set by therapeutic guidelines and state regulations.
PLEASE VISIT OUR WEBSITE TO SEE OUR COMPLETE DRUG LIST
Rx Outreach / P. O. Box 66536 / St. Louis, MO 63166-6536 / (888) RXO-1234 / www.rxoutreach.org Rev. 04/15