| Pharmaceutical Company | Astra Zeneca Foundation PAP |
| Program Address | Patient Assistance Program Astra Zeneca Foundation PO Box 15197 Wilmington DE 19850-5197 |
| Toll Free Phone Number | 800-424-3727 |
| Fax Number | n/a |
| Guidelines and Notes | Program is for patients who cannnot afford to purchase their drugs and who have no other means of obtaining them through insurance or other programs. Eligibility is case by case -- consideration is given to income/assets, insurance status and household size. Patients must be US citizens with valid social security numbers. Customer service reps are available Monday through Friday, 8:30 to 4:30 EST except holidays. Be sure form is filled out completely with no blanks (write "NA" where needed). Physicians can obtain a packet of applications from their sales reps. For information about status of mailed prescription or shipped medication, call 800-698-0085. |
| Initiating Enrollment | Obtain application and complete patient and physician sections. They will fax application but completed application must be mailed. You can download application from www.astrazeneca-us.com/pap/ Turnaround time for application is 4-6 weeks after receipt. Then allow 14 business days for shipment of medication. |
| Health Provider's Role | Doctor completes and signs application. Prescription is part of the application. |
| Patient's Role | PATIENT (or designated family member) SIGNATURE and date REQUIRED. Detailed financial and insurance information needed., including assets, gross income for each household member and non-reimbursed medical expenses. Be sure to fill out patient section completely, leaving no blanks. |
| How Dispensed | Upon approval, prescription part of application is forwarded to Express Scripts in St. Louis. They Fed Ex a 3 month supplly to "ship to" address on application, which can be patient or physician . No longer any mailing fees. |
| Amount Dispensed | Three month supply. |
| Refills | Totally new application needed once a year. A re-application is sent 45 days prior to one year expiration date.. |
| Limit | Indefinitely |