rxhelp360.org
| Drug Information | ||||||||||||||||||||||||||||||||||||||||||||
| Drug | Accolate | |||||||||||||||||||||||||||||||||||||||||||
| Generic Equivalent | zafirlukast | |||||||||||||||||||||||||||||||||||||||||||
| Class | Asthma | |||||||||||||||||||||||||||||||||||||||||||
| Topic | Pulmo | |||||||||||||||||||||||||||||||||||||||||||
| Program Contact Info / Application Submission | ||||||||||||||||||||||||||||||||||||||||||||
| Program | Astra Zeneca Foundation Patient Assistance Program | |||||||||||||||||||||||||||||||||||||||||||
| Company | AstraZeneca | |||||||||||||||||||||||||||||||||||||||||||
| Form | Download PDF | |||||||||||||||||||||||||||||||||||||||||||
| Address | PO Box 66551, St. Louis, MO 63166-6551 | |||||||||||||||||||||||||||||||||||||||||||
| Phone | 800-424-3727 | |||||||||||||||||||||||||||||||||||||||||||
| Fax | 888-810-5282 | |||||||||||||||||||||||||||||||||||||||||||
| Website | http://www.astrazeneca-us.com/content/drugAssistance/ | |||||||||||||||||||||||||||||||||||||||||||
| Program Details | ||||||||||||||||||||||||||||||||||||||||||||
| Details | A 90-day supply is sent to either the doctor�s office, patient's home, hospital or pharmacy. Patients or doctors must contact the company for refills. A new application with documentation is needed once a year. | |||||||||||||||||||||||||||||||||||||||||||
| Program Requirements | ||||||||||||||||||||||||||||||||||||||||||||
| Information | All signatures must be original, and proof of income must include tax forms as well as current proof. | |||||||||||||||||||||||||||||||||||||||||||
| Details | Insurance card required Drivers license required Proof of Income NOT required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income Notarized statement from patient stating zero income required as proof of income | |||||||||||||||||||||||||||||||||||||||||||
| Delivery of Medication | ||||||||||||||||||||||||||||||||||||||||||||
| Ship Time | 2-4 weeks | |||||||||||||||||||||||||||||||||||||||||||
| Delivery Options | Can NOT be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card | |||||||||||||||||||||||||||||||||||||||||||
| Application Process | ||||||||||||||||||||||||||||||||||||||||||||
| App Process | Anyone requesting assistance can call to request a mailed application or download it from the website. The completed application must be mailed back. If the patient is denied, both patient and doctor are notified. Once approved medicines are shipped out with in 5-7 business days. | |||||||||||||||||||||||||||||||||||||||||||
| New Applications | New applications NOT accepted Patients can NOT apply directly to the program Doctors can NOT apply directly to the program Advocates can NOT apply directly to the program Can apply for a new application via phone Can apply for a new application via fax Can NOT apply for a new application via mail | |||||||||||||||||||||||||||||||||||||||||||
| Refills | Refills NOT accepted Patients can NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can NOT apply for refills via phone Can apply for refills via fax Can NOT apply for refills via mail | |||||||||||||||||||||||||||||||||||||||||||
| Re-Applications | Re-Applications NOT accepted Patients can NOT apply for Re-Applications Doctors can NOT apply for Re-Applications Advocates can NOT apply for Re-Applications Can Re-Apply via phone Can Re-Apply via fax Can NOT Re-Apply via mail | |||||||||||||||||||||||||||||||||||||||||||
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals NOT accepted Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can apply for an appeal via phone Can apply via fax Can NOT apply for an appeal via mail | |||||||||||||||||||||||||||||||||||||||||||
| Eligibility | ||||||||||||||||||||||||||||||||||||||||||||
| 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. Patients who are eligible for Medicare Part D but have not enrolled may still eligible for this program. The application for this program and the AstraZeneca Cancer Support Network Patient Assistance Program is the same and says 'Application for Free AstraZeneca Medicines' on the upper left side. | |||||||||||||||||||||||||||||||||||||||||||
| Limitations | Patients are NOT eligible if LIS is denied Patients are eligible with existing prescription coverage Patients are NOT eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are NOT eligible if they are accepting Medicare Patients are eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted | |||||||||||||||||||||||||||||||||||||||||||
| Appeals | ||||||||||||||||||||||||||||||||||||||||||||
| Conditions | Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied | |||||||||||||||||||||||||||||||||||||||||||
| Other Medications | ||||||||||||||||||||||||||||||||||||||||||||
| Other Medications available in this program |
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