| Pharmaceutical Company | Zeneca Pharmaceuticals |
| Program Address | Patient Assistant Program P. O. Box 15197 Wilmington, DE 19850-5197 |
| Toll Free Phone Number | 800-424-3727 |
| Alternate Phone Number | 800-698-0085 |
| Fax Number | None |
| Guidelines and Notes |
Call 9:00 A.M. to 4:00 P.M. Eastern Time. Eligibility is based on income level/assets and no prescription coverage. When submitting the application make sure no questions are left unanswered. If the question doesn't apply, write "NA" or similar term. They will return applications that contain blanks. Zoloadex requires additional approval from the company and prescriptions must be written for one dose of 3.6 mg depot or 1 dose of 10.8 mg depot. Prescriptions for more than one depot can't be honored. |
| Initiating Enrollment | They will take patient information over the phone from a social worker or the physician's office. The form will have the patient's name on it, so it can't be copied. |
| Health Provider's Role | The doctor completes, signs, and sends the form. A prescription for a three month, 100 day supple needs to be attached. |
| Patient's Role | Provides detailed financial and insurance information. The patient's signature is required. |
| How Dispensed |
Upon approval, an Express Scripts mailer is sent to the patient. The patient puts his/her prescription and a $5.00 money order and mails it to Express Scripts. The medicines are sent by Federal Express directly to the patient. Zoladex is sent to the doctor. All medicine packages are sent with a mailer for refill requests. |
| Amount Dispensed | Prescriptions must be written for a three-month, 100 day supply. All bottles contain 100 tablets except for Acolate (60 per bottle) and Armidex (30 per bottle). |
| Estimated Response Time | Not specified |
| Refills | A new application is need annually. The company automatically sends one to the patient. |
| Limit | Indefinite |