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AstraZeneca Cancer Support Network (AZ CSN)
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PO Box 66551
St. Louis, MO 63166-6551
Phone
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866-992-9276
Fax:
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Eligibility
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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
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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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. |
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Supply
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Up to a 60-day supply |
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Ship To
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Either Doctor's office or Patient's home |
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Note
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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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.
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| Zoladex Depot |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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