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Azilect Patient Assistance Program
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PO Box 139
Somerville, NJ 08876
Phone
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866-217-7163
Fax:
866-838-5832
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 350% of the Federal Poverty Level. The patient must also be a US citizen or legal resident. |
| Who Can Apply
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The doctor or patient can call to request an application be faxed or mailed. |
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Required
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The doctor must fill out a section, sign the application and attach required documents.The patient must fill out a section, sign the application and attach required documents. |
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Supply
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Not specified |
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Ship To
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Patient's home, unless otherwise noted |
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Note
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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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| Azilect Tablets |
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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 |
| Download printable Form |
(Requires Acrobat Reader) 
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