PACT+ Program


Contact Information
PACT+ Program
PO Box 1074
San Bruno, CA 94066
1-(800) 996-6626 (phone)
1-(800) 996-6627 (fax)
How to Apply:
Select one of the links below to download the application or go to the program site for more information on how to apply. Once you fill out your application, send it to the address on the application. Do NOT send it to RxResource.
1. The patient must have no prescription coverage or have reached their cap. Patient's total annual household income must be below 500% of FPL. 2. The patient must be a US citizen or resident. 3. The application must be filled out completely. The physician must sign the application and attach a prescription. In addition, the patient must sign the authorization forms. The physician is notified of acceptance or denial with in 2 business days. If approved, medication is shipped the next business day to the physician's office. 4. A Reorder Form (submitted by the physician's office) is required for each refill. 5. Patient eligibility is for one year, after which a new application is needed.
Other Information:
Anyone concerned can call PACT+ for an application or download it from the web site. The completed application can be faxed or mailed back. Applications & Reorder Forms may also be submitted via the program's secure, web-based provider portal at
Product(s) covered by program:
  • Anzemet® Tablets
  • Elitek
  • Eloxatin
  • Jevtana
  • Nilandron™
  • Oforta
  • Taxotere