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Program Details

IMPAX LABORATORIES, INC.
Impax Patient Assistance Program

Zomig (tablets) (zolmitriptan)
 
CONTACT INFO
Address: PO BOX 66554
ST. LOUIS, MO 63166-6554
Phone: 1-877-764-9021 Provider Phone:
Fax: 1-877-764-9022 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must not have affordable coverage for the prescription.
  • Patient must meet program income guidelines which are not disclosed.
  • Patients with Medicare Part D must have spent at least 3% of annual household income out-of-pocket on prescription medications.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Prescription
    Physician License #
    Required:
    Either DEA or State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: Vaires
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Program will send an application for renewal when patient's enrollment is due to expire.
    Refill Policy: Not Published
    Other Information:

    Last Updated: 01/22/2018

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Instructions (English)



     

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