rxhelp360.org
| Drug Information | |
| Drug | Zomig tablet 2.5mg |
| Generic Equivalent | zolmitriptan |
| Class | triptan |
| Topic | Migraine |
| 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 NOT required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero incomeNOT required as proof of income Form 4506T (If taxes were not filed) required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income NOT required as proof of income |
| Delivery of Medication | |
| Ship Time | 2-4 weeks |
| Delivery Options | Can be delivered directly to the patient Can be delivered directly to the doctor |
| 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 accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can NOT apply for a new application via fax Can apply for a new application via mail |
| Refills | Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can apply for refills Can apply for refills via phone Can NOT apply for refills via fax Can apply for refills via mail |
| Re-Applications | Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can NOT Re-Apply via fax Can Re-Apply via mail |
| Appeals | Income Appeals accepted Patients can apply for Income Appeals Doctors can apply for Income Appeals Advocates can apply for Income Appeals Hardship Appeals accepted Patients can apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can 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 eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are NOT eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted |
| Appeals | |
| Conditions | Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals must be made after the patient has been denied |
| Other Medications | |
| Other Medications available in this program | |
|
|
||||||||||||||||||||
|
|
||||||||||||||||||||
