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Patient Assistance Information

 
2 Programs for Zomig Nasal Spray
 
 
AZ&Me Prescription Savings Program for People Without Insurance

PO Box 66551
St. Louis, MO 63166-6551
Phone : 800-424-3727
Fax: (800)961-8323
Eligibility
> The patient may have isnurance and an income at or below $35,000 for an individual; $48,000 for a couple; $60,000 for a family of three; $70,000 for a family of four. The patient must also be a US resident or have a valid visa or is a green card holder. Patients who are eligible for Medicare Part D but have not enrolled may still eligible for this program. The application for this program and the AstraZeneca Cancer Support Network Patient Assistance Program is the same and says 'Application for Free AstraZeneca Medicines' on the upper left side.People who are in Medicare and may be eligible for the Limited Income Subsidy can apply.However if they are accepted into the LIS, they are no longer eleigible for the AZ& ME program.
Who Can Apply
> Anyone requesting assistance can call to request a mailed application or download it from the website.
Required
> The doctor needs to provide a prescription to the patient. The patient must fill out a section, sign the application and attach proof of income.
Supply
>
Ship To
> Either Doctor's office or Patient's home
Note
> The patient or doctor must contact the company for refills. The patient must reapply once a year.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Zomig Nasal Spray
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Impax Patient Assistance Program

PO Box 66554
St. Louis, MO 63166
Phone : 877-764-9021
Fax: 877-764-9022
Eligibility
> The Impax Patient Assistance Program provides brand name medications at no or low cost and is intended for patients that are uninsured or underinsured. Eligibility for patients with Medicare Part D will be determined on a case by case basis. Income requirements for this program have not been disclosed. Patients must be a US resident.
Who Can Apply
> Patients and doctors can apply by calling or downloading the application.
Required
> Patients and physician's must complete and sign the application. Proof of income must be faxed along with the application. Patient and physicians will be notified by mail withing 7-10 days.
Supply
> Supply varies.
Ship To
> Medication will be shipped to the patients home within 7-10 days.
Note
> Those with Medicare Part D must have spent at least 3% of annual household income out-of-pocket on prescription medicines. Contact program for Spanish application.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Zomig Nasal Spray
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader