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Patient Assistance Information

 
2 Programs for Zomig Tablets
 
 
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.
 
Zomig Tablets
 
 
 
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 Tablets
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader