Program Applications

Tips for using the applications:

  • You will need Adobe Reader to open the applications. Download this free program or the latest version, which is recommended.
  • Click the button in the top right of the application to turn on the Highlight Fields Option which will highlight the fields to be filled out.
  • Use the "tab" key to easily go to the next field.

As of 12/21/2014 there are 607 applications available.

Click on the first letter of the name of the program. Then click on the application for that program. Dates next to each listing reflect the last update. Some applications may need to be opened with a different viewer depending on which browser you are using. Firefox users may get a message saying "This PDF document might not be displayed correctly." Try clicking on the "Open With Different Viewer" option. If you are still unable to interactively complete the application, use a different browser.

Send the completed application to the address on the application and not to NeedyMeds.

If you cannot find an application or are having trouble printing one, contact the program or company.

Contact NeedyMeds if you find any content errors.

For link problems or other technical problems, send an email to webmaster.

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AbbVie Patient Assistance Foundation Application 10/02/14
AbbVie Patient Assistance Foundation Application for Androgel 12/10/14
AbbVie Patient Assistance Foundation Application for Creon 12/10/14
AbbVie Patient Assistance Foundation Application for HUMIRA 10/02/14
AbbVie Patient Assistance Foundation Application for Lupron Depot 10/02/14
AbbVie Patient Assistance Foundation Application for Moderiba 10/02/14
AbbVie Patient Assistance Foundation Application for Norvir and Kaletra 10/02/14
AbbVie Patient Assistance Foundation Application for Zemplar 10/02/14
AbbVie Patient Assistance Foundation for Marinol: Contact program
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Androgel 10/02/14
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Creon 10/02/14
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Humira 10/02/14
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Kaletra 10/02/14
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Moderiba 10/02/14
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Norvir 10/02/14
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Synthroid 10/02/14
AccessDIFICID Intake Form 08/26/14
AccessDIFICID Intake Form (Spanish) 08/26/14
AccessPro Program for SAMSCA Enrollment Form 09/26/14
AccessSivextro Enrollment Form 09/19/14
AccessSivextro Program Information 09/19/14
ACT Program Enrollment Form 09/26/14
ACT Program Enrollment Form (Spanish) 09/26/14
Actavis Patient Assistance Program Application 12/16/14
Actavis Patient Assistance Program Application Form for Gelnique 10/28/14
Actavis Patient Assistance Program Application Form for Infed, Rapaflo, and Trelstar 10/28/14
Actelion Pathways Enrollment Form: Contact program
Acthar Support & Access Program Start Form 08/14/14
Adasuve REMS Program Brochure 12/01/14
Adasuve REMS Program Physician Letter 12/01/14
Adempas Patient Enrollment and Consent Form 12/19/14
Adempas Prescriber Enrollment and Agreement Form 12/19/14
Akrimax Patient Assistance Program Enrollment Form 10/13/14
Alcon Cares Application 09/24/14
Alexion Complement Foundation: Contact program
Allergan Patient Assistance Program Application 12/17/14
Alpha-1 AATmosphere Program Enrollment Form 11/11/14
Alphanate Savings Card Program: Contact program
AlphaNine SD Savings Card Program Brochure: Contact program.
AMAG Assist Reimbursement Enrollment Form 12/19/14
Amedra Cares Patient Assistance Program Application 07/14/14
American Regent Patient Assistance Program (Injectafer) Application 10/13/14
American Regent Patient Assistance Program (Injectafer) Request Form 10/13/14
American Regent Patient Assistance Program (Venofer) Application 10/13/14
American Regent Patient Assistance Program (Venofer) Request Form 10/13/14
Amgen FIRST STEP Co-Pay Support: Contact program
Ampyra Patient Support Services Center Prescription & Service Request Form 11/10/14
Ampyra Patient Support Services Center Prescription & Service Request Form for Co-Pay 10/07/14
Angiomax Reimbursement and Patient Financial Assistance Program Application 09/22/14
Aptalis Patient Assistance Program Application: See Actavis Patient Assistance Program
Arbor Gliadel Wafer Patient Assistance Program Application 10/15/14
Arbor Patient Assistance Program Application 10/15/14
Arch Foundation Patient Assistance Program for Mirena Application 10/02/14
Arch Foundation Patient Assistance Program for Mirena Application (Spanish) 10/02/14
Ariad PASS Prescription Form 10/14/14
ASSIST Program: Contact program
Assure Access Program Enrollment Form 08/13/14
Astellas Access Program (PROGRAF): Contact program
Astellas Access Program (PROTOPIC): Contact program
Astellas Access Program (VESICARE and MYRBETRIQ): Contact program
Astellas Access Program (XTANDI): Contact program
Astellas Access Program for ASTAGRAF XL: Contact program
Astellas Stock Replacement Program For AmBisome: Contact program
Astellas Stock Replacement Program For Lexiscan: Contact program
Astellas Stock Replacement Program For MYCAMINE: Contact program
Atripla Patient Assistance Program Application 07/17/14
Auxilium Patient Assistance Program Application for Xiaflex 09/09/14
Avonex ecoSharps Disposal Program: Contact program
AZ&Me Prescription Savings Program with Med D Application 10/03/14
AZ&Me Prescription Savings Program with out Med D Application 10/03/14
Azilect Patient Assistance Program Application 09/18/14
Azilect Patient Assistance Program Application (Spanish) 09/18/14

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