BupeRXsolutions Subutex Mail Order Pharmacy Enrollment Form

Get Subutex Medication delivered directly to your door for as low as $99 per month.

A member of our team will contact you via text to confirm your eligibility.

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Name *

First

Last

Email *

Phone *

Are you currently in treatment? *

• Yes
• No

Which office or clinic do you visit for your Subutex treatment? (Please specify) *

What is your monthly cost for treatment appointments? (Please specify) *

How long have you been receiving treatment? *

• 1-6 months
• 6-12 months
• 1-3 years
• More than 3 years

What is your current monthly expenditure for Subutex medication? *

• $150-$200
• $200-$300
• $300+

Which pharmacy do you currently use? (Please specify) *

In which state do you reside? (Please specify) *

Disclaimer *

• I agree to the terms and conditions listed below.

Please note that BupeRXsolutions’ partner pharmacies do not accept insurance for Buprenorphine products, so you will be responsible for the full cost of your prescription. Our service includes 2-3 day shipping at no extra cost, and medications are delivered directly to your home, provided you are eligible. Currently, we serve customers in Pennsylvania, Ohio, West Virginia, and Maryland.


Upon confirming your eligibility, our team will text you with the next steps to arrange for your medication delivery.

Submit