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 08/31/2015 there are 635 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 06/15/15
AbbVie Patient Assistance Foundation Application for Androgel 06/15/15
AbbVie Patient Assistance Foundation Application for Creon 06/15/15
AbbVie Patient Assistance Foundation Application for HUMIRA 06/15/15
AbbVie Patient Assistance Foundation Application for Lupron Depot 06/15/15
AbbVie Patient Assistance Foundation Application for Moderiba 06/15/15
AbbVie Patient Assistance Foundation Application for Norvir and Kaletra 06/15/15
AbbVie Patient Assistance Foundation for Marinol: Contact program
AbbVie Patient Assistance Foundation Medicare D Attestation Form 06/15/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Androgel 06/15/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Creon 06/15/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Humira 06/18/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Kaletra 06/15/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Moderiba 06/15/15
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Norvir 06/15/15
AccessCubicin Copay Program Enrollment Form 07/17/15
AccessCubicin Patient Assistance Program Form 07/17/15
AccessCubicin Program Enrollment Form 07/17/15
AccessDIFICID Program Enrollment Form 07/17/15
AccessSivextro Program Enrollment Form 07/17/15
AccessZerbaxa Program Enrollment Form 07/17/15
ACT Program Enrollment Form 07/28/15
ACT Program Enrollment Form (Spanish): Contact program
Actavis Patient Assistance Program Application 06/30/15
Actelion Pathways Enrollment Form: Contact program
Acthar Start Form 06/30/15
Adasuve REMS Program Brochure 06/25/15
Adasuve REMS Program Physician Letter 06/25/15
Adempas Patient Enrollment and Consent Form 06/18/15
Adempas Prescriber Enrollment and Agreement Form 06/18/15
Afrezza Statement of Medical Necessity 07/15/15
Afrezza Support Program: Contact program
Akorn Patient Assistance Program Application 08/21/15
Akrimax Patient Assistance Program Enrollment Form 07/09/15
Alcon Cares Application 08/24/15
Alexion Complement Foundation: Contact program
Allergan Patient Assistance Program Application 08/24/15
Alpha-1 AATmosphere Program Enrollment Form 11/11/14
AMAG Assist Reimbursement Enrollment Form 12/19/14
Amedra Cares Patient Assistance Program Application 07/09/15
American Regent Patient Assistance Program Application 07/13/15
American Regent Patient Assistance Program Request Form 07/13/15
Amgen FIRST STEP Co-Pay Support: Contact program
Ampyra Patient Support Services Center Prescription & Service Request Form 06/05/15
Ampyra Patient Support Services Center Prescription & Service Request Form for Co-Pay 06/05/15
Angiomax Reimbursement and Patient Financial Assistance Program Application 07/29/15
Arbor Gliadel Wafer Patient Assistance Program Application 07/13/15
Arbor Patient Assistance Program Application 07/08/15
ARCH Patient Assistance Program Application Form 06/05/15
ARCH Patient Assistance Program Application Form (Spanish) 06/05/15
Arestin Rx Access Patient Eligibility Form 04/27/15
Ariad PASS Prescription Form 07/09/15
ASSIST Program: Contact program
Assure Patient Assistance Enrollment Form for Rexulti 08/27/15
Assure Patient Enrollment Form for Abilify Maintena 08/04/15
Assure Patient Enrollment Form for Rexulti 08/27/15
Astellas Pharma Support Solutions (XTANDI) 08/13/15
Astellas Pharma Support Solutions Enrollment Form (CRESEMBA) 08/13/15
Astellas Pharma Support Solutions: 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 08/04/15
Auxilium Copay Savings Program Reimbursement Form 07/13/15
Auxilium Patient Assistance Program Application for Xiaflex 07/13/15
AZ&Me Prescription Savings Program with Med D Application 07/09/15
AZ&Me Prescription Savings Program with out Med D Application 04/06/15
Azilect Patient Assistance Program Application 06/26/15
Azilect Patient Assistance Program Application (Spanish) 06/26/15

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