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 08/25/2016 there are 598 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 06/16/16
AbbVie Patient Assistance Foundation Application for Androgel 06/16/16
AbbVie Patient Assistance Foundation Application for Creon 06/16/16
AbbVie Patient Assistance Foundation Application for HUMIRA 06/16/16
AbbVie Patient Assistance Foundation Application for Lupron Depot 06/16/16
AbbVie Patient Assistance Foundation Application for Marinol 06/20/16
AbbVie Patient Assistance Foundation Application for Norvir and Kaletra 06/16/16
AbbVie Patient Assistance Foundation for Technivie: Contact program
AbbVie Patient Assistance Foundation for Viekira Application 08/17/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form 06/16/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form 06/17/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Kaletra 06/17/16
AbbVie Patient Assistance Foundation Medicare D Attestation Form for Norvir 06/16/16
Access 360 Patient Authorization Form (PAF) Oncology 06/21/16
Access 360 Patient Authorization Form (PAF) Oncology (Spanish) 06/21/16
Access 360 Request Form 06/21/16
AccessPlus Financial Assistance Brochure 08/19/16
AccessPlus Patient Assistance Program Enrollment Form 08/19/16
AccessPlus Patient Guide 08/19/16
AccessZerbaxa Program Enrollment Form 08/23/16
Accredo Patient Assistance Program for Carbaglu: Contact program
Actavis Patient Assistance Program Application 06/30/16
Actavis Patient Assistance Program Application Instruction Letter & Product List 06/30/16
Actelion Pathways Enrollment Form: Contact program
Acthar Ophthalmology Start Form 07/26/16
Acthar Start Form 07/26/16
Adasuve REMS Program Brochure 07/08/16
Adasuve REMS Program Physician Letter 07/08/16
Addyi Medication Guide 07/14/16
Addyi REMS Patient-Provider Agreement Form 07/14/16
Addyi REMS Prescriber Enrollment Form 07/14/16
Adempas Patient Enrollment and Consent Form 03/07/16
Adempas Prescriber Enrollment and Agreement Form 03/07/16
Akorn Patient Assistance Program Application: Contact program
Akrimax Patient Assistance Program Enrollment Form 06/09/16
Alexion Access Foundation: Contact program
Allergan Patient Assistance Program Application 06/17/16
Alpha-1 AATmosphere Program: Contact program
AMAG Assist Reimbursement Enrollment Form 06/01/16
American Regent Patient Assistance Program Application 05/31/16
American Regent Patient Assistance Program Request Form 05/31/16
American Regent Reimbursement Brochure 05/31/16
Amgen FIRST STEP Co-Pay Support: Contact program
Ampyra Patient Support Services Center Prescription & Service Request Form 07/14/16
Ampyra Patient Support Services Center Prescription & Service Request Form for Co-Pay 07/14/16
Angiomax Reimbursement and Patient Financial Assistance Program Application 08/19/16
Aptevo Therapeutics Reimbursement and Patient Assistance Program Application 08/01/16
Arbor Gliadel Wafer Patient Assistance Program Application 08/24/16
Arbor Patient Assistance Program Application 08/04/16
ARCH Patient Assistance Program Application Form 06/16/16
ARCH Patient Assistance Program Application Form (Spanish) 06/16/16
Arestin Rx Access Patient Eligibility Form 05/12/16
Ariad PASS Prescription Form 08/04/16
Aristada Care Support Patient Assistance Program Enrollment Form 08/10/16
ASSIST Program: Contact program
Assure for Abilify Tablets Patient Enrollment Form 05/23/16
Assure Patient Enrollment Form for Abilify Maintena 08/18/16
Assure Patient Enrollment Form for Rexulti 08/18/16
Astellas Pharma Support Solutions (XTANDI) Patient Enrollment Form 07/25/16
Astellas Pharma Support Solutions Enrollment Form (CRESEMBA) 06/14/16
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
Auxilium Copay Savings Program Reimbursement Form 08/12/16
Auxilium Patient Assistance Program Application for Xiaflex 08/12/16
Avanir Brochure for Nuedexta 08/08/16
Avanir Brochure for Onzetra Xsail 08/08/16
Avanir Patient Services (APS) Enrollment Form 08/08/16
AZ&Me Prescription Savings Program with Med D Application 06/28/16
AZ&Me Prescription Savings Program with out Med D Application 06/28/16
Azilect Patient Assistance Program Application 07/14/16
Azilect Patient Assistance Program Application (Spanish) 07/14/16

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