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Patient Assistance Information

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