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Azopt

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Novartis Patient Assistance Foundation, Inc.

This program provides brand name medications at no or low cost.

Provided by: Novartis Pharmaceuticals

PO Box 52029
Phoenix, AZ 85072-2029

TEL: 800-277-2254


FAX: 855-817-2711
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Novartis Patient Assistance Foundation, Inc. Enrollment Application

 Novartis Patient Assistance Foundation, Inc. Enrollment Application (Spanish): Contact program

 

Medications

  • Azopt ophthalmic suspension/drops (brinzolamide)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed
Returning Fax or mail
Doctor's Action Complete section, sign, attach prescription for 90 days
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Doctor notified via mailed letter
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient is sent card to be used at pharmacy
Delivery Time Not specified
Refill Process Refill/reorder form included with shipment
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information

For Focalin XR, Clozaril, and Ritalin LA, Clozarila pharmacy card will be issued. All other medication will be shipped directly to the physician.

*Additional products may be available. Please contact the program for a complete product listing. www.pap.novartis.com
Updated August 15, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Azopt

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Xubex Patient Assistance Program

This program provides medication at low cost. (Most brand names are provided for reference purposes only.)

Provided by: Xubex

PO Box 1244
Winter Park, Fl 32790-1244

TEL: 866-699-8239


ALT PHONE: 407-478-2663
FAX: 407-671-7960
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Xubex Patient Assistance Program Registration Form (pages 1 & 2)

Xubex Patient Assistance Program Physician Order Sheet (page 3)

 

Medications

  • Azopt (brinzolamide)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes, but contact program for details
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Varies per medication
Re-application New application, new documentation yearly
   

Additional Information

No proof of income is required. Check the website for the exact price.

This service is not currently available in Montana.


Updated August 05, 2016