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Patient Assistance Information

 
1 Program for Zoladex 3-month Depot
 
 
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.
 
Zoladex 3-month Depot
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader