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 |
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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. |
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