IBSA offers a patient assistance program providing IBSA brand name medications to individuals who meet eligibility requirements. Eligibility is based on your annual household income, prescription insurance and residency status. Patients on government health plans like Medicare and Medicaid are not eligible.

To see if you meet the program’s eligibility requirements, complete and return the enrollment form. If you qualify, you will automatically be mailed your first 90-day supply. You will then be eligible to receive free medicine(s) for the remainder of the calendar year by calling to refill your prescription. You must re-enroll and re-qualify for each calendar year to remain in the program.

Call

(833) 838-3247

Eligible Medicine

  • Tirosint® (Levothyroxine Sodium) – Not available to new patients. Patients currently enrolled in the program are allowed to continue
  • Tirosint-Sol® (Levothyroxine Sodium Oral Solution) – Available to new patients and patients wishing to continue in the program

2020 Program Annual FPL Guidelines

Family size123456788+
200% – 48 States$25,520$34,480$43,440$52,400$61,360$70,320$79,280$88,240 + $4,480/add’l person
200% – Alaska $31,900$43,100$54,300$65,500$76,700$87,900$99,100$110,300 + $5,600/add’l person
200% – Hawaii $29,360$39,660$49,960$60,260$70,560$80,860$91,160$101,460 + $5,150/add’l person

1

Download Enrollment Form

Download PDF

2

Complete Enrollment Form

Remember to include your name & date of birth on all attachments.
Be sure your application is complete. Questions? Call:

(833) 838-3247

3

Return Form

Please include all pages of the completed enrollment form and income documentation.

By Mail:
IBSA Patient Assistance Program
PO Box 1229, Southampton, PA, 18966

By Fax**:
(833) 340-7196

**Faxes will be accepted only when faxed directly from a prescriber’s office to the program. The fax must include a cover page with the prescriber’s contact information, medical provider address, NPI number and patient name. Faxes without this information will not be accepted and will be discarded.

Refill Information

Once you are enrolled, ordering a refill is easy. Just call (833) 838-3247 up to 2 weeks before your supply of medicine runs out.