Azilect Patient Assistance Program - Needymeds

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Form from
AZILECT® (rasagiline tablets)
Phone: (866) 217-7163
P. O. Box 139
Patient Assistance Program (PAP)
Somerville, NJ 08876
Fax: (866) 838-5832
How to Apply:
Patient Instructions:
q Complete and sign page 1 (Patient Information).
q Attach copy of most recent Federal tax return.
— If you do not file a Federal tax return, please attach other proof of yearly household income (such as W-2, 1099,
unemployment award letter, social security, disability or pension statement) for everyone living with you.
— If you have Medicare Part D drug coverage, attach a copy of the front and back of your Medicare drug card, and attach proof that you
are in the coverage gap, such as a pharmacy printout that shows what you paid for AZILECT® and what your Medicare drug plan paid.
q Ask your doctor to complete and sign page 2 (Prescribing Practitioner Information).
q Mail form and a copy of proof of income to:
AZILECT® Patient Assistance Program, P.O. Box 139, Somerville, NJ 08876, or fax to 866-838-5832.
— If you have a Medicare Part D drug plan, include:
q copy of Medicare drug card
q pharmacy printout
Practitioner Instructions:
q Complete and sign page 2 Prescribing Practitioner Information (Practitioner section — no signature stamps, please).
q Either complete Prescription Information OR include an original prescription for a 3-month supply of AZILECT®.
q All orders will be shipped to the patient, unless otherwise indicated.
q If you are assisting a patient in completion of this form, please refer to patient instructions above.
Available Products
AZILECT® 0.5 mg
AZILECT® 1.0 mg
Who Can Enroll (Program Eligibility):
q Patient must be a legal resident of the United States.
q Patient cannot have any private outpatient drug coverage for AZILECT®, such as an HMO or PPO plan.
q Patient with Medicare Part D drug coverage can enroll if patient is in the coverage gap (“donut hole”).
Patient cannot have any other government drug coverage for AZILECT® such as Medicaid, Veteran’s Administration,
or any state or local program.
q Patient’s yearly household income must be at or below 350% of the current Federal Poverty Level. See chart below for the
income limit per household size:
Number of People in Household
Limit on Total Yearly Household Income
How to get a Refill:
q The patient or practitioner may ask for a refill by phone. Call 866-217-7163, then press 4 and follow instructions.
q The practitioner may submit a completed application to request a refill. Refills do not require proof of income.
How and When to Re-enroll:
q Medicare patients must send a new form each calendar year — when they enter the Part D coverage gap.
q To stay in the program, all other patients must send a new form every 12 months with proof of household income. Both patient and
practitioner must complete and sign the form.


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