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Patient Assistance Information

 
5 Programs for Faslodex Injection
 
 
AstraZeneca Cancer Support Network (AZ CSN)

PO Box 66551
St. Louis, MO 63166-6551
Phone : 866-992-9276
Fax:
Eligibility
> The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below $30,000 for an individual; $40,000 for a couple; $50,000 for a family of three; $60,000 for a family of four. The patient must also be a US resident or have a valid visa or is a green card holder.
Who Can Apply
> Anyone requesting assistance can call to request a faxed 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
> Up to a 60-day supply
Ship To
> Either Doctor's office or Patient's home
Note
> Anyone requesting assistance can call to request a faxed application or download it from the website.
 
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.
 
Faslodex Injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
AZ&Me Prescription Savings Program for People with Medicare Part D


,
Phone : 800-292-6363
Fax:
Eligibility
> The patient must have Medicare Part D, and have an income less than or equal to $30,000 for an individual (less than or equal to $40,000 for a couple.)
Who Can Apply
> The patient should call for a prescreening or go to the website and apply on line.
Required
> The patient must provide information and proof of income.
Supply
> The Patient is sent an enrollment kit and a program card that they can use at their local pharmacy to receive their AstraZeneca medications for no more than $25 for a typical 30-day prescription.
Ship To
> Patient's home
Note
> The patient should call for a prescreening or go to the website and apply on line.
 
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.
 
Faslodex Injection
 
 
 
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.
 
Faslodex Injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Diplomat's Co-Pay Assistance Navigator Program

Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone : (877)977-9118 Ext 89864
Fax: (810)282-0176
Eligibility
> Insurance determined case by case. Medicare Part D patients are eligible for this program. Income requirements determined case by case. Must be a US resident. Must have medically appropriate condition/diagnosis.
Who Can Apply
> Patient or Doctor may call to receive application via fax or mail. May also complete application online. Application is to be mailed or faxed back to company.
Required
> Doctor's action will be discussed with patient and Doctor after request is received. Patient must complete application, sign and provide annual income information. Proof of income may be requested by program at any time. Patient and/or Doctor are notified of decision within 1-2 business days.
Supply
> Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case.
Ship To
> Once approved medication is shipped to Patient's home within 2 business days.
Note
> Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie
 
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.
 
Faslodex Injection
 
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US.
Who Can Apply
> Patients or healthcare providers can complete the application online or by phone.
Required
> Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
 
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.
 
Faslodex Injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader