| CONTACT
INFO |
|
| Address: |
1 Medimmune Way
Gaithersburg, MD 20878 |
| Phone: |
1-800-292-6363 |
Provider Phone: |
|
| Fax: |
1-877-239-0876 |
Website: |
AZ & Me Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Visit AZ&Me website to apply online or to download an application.
Patient must meet qualifying income criteria.
Patient must be enrolled in Medicare and are not enrolled in Limited Income Subsidy (LIS).
|
| |
Couple |
|
% FPL |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
Prescription
Year-to-date prescription spend history
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Providers receive a fax, patient receives letter and phone call
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Either Provider and Patient
|
| Quantity in
Shipment: |
Varies by product |
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
Enrollment is on a calendar year basis, with opportunity to re-enroll.
|
| Refill Policy: |
Refills can be requested by calling the Program |
| Other Information: |
Individuals can also apply online, download an application at www.azandme.com. |
|