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Patient Assistance Information

 
 
 
Azilect Patient Assistance Program

PO Box 139
Somerville, NJ 08876
Phone : 866-217-7163
Fax: 866-838-5832
Eligibility
> 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
> The doctor or patient can call to request an application be faxed or mailed.
Required
> 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.
Supply
> Not specified
Ship To
> Patient's home, unless otherwise noted
Note
>
 
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.
 
Azilect Tablets
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader