Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Edarbi

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Arbor Patient Assistance Program

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

Provided by: Arbor Pharmaceuticals, LLC.

951 Clint Moore Road
Suite A
Boca Raton, FL 33487

TEL: 888-417-7153


FAX: 407-641-9566
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Arbor Patient Assistance Program Application

 

Medications

  • Edarbi tablet (azilsartan medoxomil)
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? Yes, but have been denied or are ineligible for Low Income Subsidy
Income At or below 300% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign, attach proof of income and include Medicaid denial letter
Decision Communicated Patient and Doctor are notified
Decision Timeframe 2-4 weeks
   

Medication

Amount/Supply Up to 90 day supply
Sent To Doctor's office
Delivery Time Within 5-7 business days
Refill Process Patient must contact company
Limit None
Re-application New application yearly
   

Additional Information

Must be at or below 300% FPL for BiDil.
Must be at or below 200% FPL for all other medications.

Updated July 08, 2015


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

Edarbi

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Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Edarbi tablet (azilsartan medoxomil)
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Updated July 10, 2015