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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Cayston Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Gilead Sciences, Inc.

PO Box 13185
La Jolla, CA 92039-3185

TEL: 877-722-9786


ALT PHONE: 877-290-6014
FAX: 877-550-1705
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Cayston Patient Assistance Program Patient Enrollment Form

 

Medications

  • aztreonam (Cayston) 
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income Based on FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be a US resident
   

Application

Obtaining Call
Receiving Faxed or mailed
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Up to 1 month supply
Sent To Patient's home, unless otherwise noted
Delivery Time Within 2 business days
Refill Process Patient contacts pharmacy
Limit Not specified
Re-application Not specified
   

Additional Information


Updated October 19, 2017


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

HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program: Contact program

 

Medications

  • aztreonam (Cayston) 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated May 22, 2017