| |
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) 
|
| |
|
|