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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Patient Access Program (Katerzia)

This program provides brand name medications at no or low cost

Provided by: Azurity Pharmaceuticals, Inc.

1710 N Shelby Oaks Dr. #1
Memphis, TN 38134

TEL: 844-472-2032


FAX: 866-927-2052
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Katerzia Patient Assistance Program Form

Katerzia Patient Enrollment and Prescription Form

 

Medications

  • amlodipine benzoate oral suspension (Katerzia) Oral Suspension
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured with no prescription coverage for needed medication
Those with Part D Eligible? Yes, if product is not covered
Income Not disclosed
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Download from website
Receiving Downloaded from website
Returning Fax or mail from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified by phone
Decision Timeframe Not specified
   

Medication

Amount/Supply 30 day supply
Sent To Patient's home, unless otherwise noted
Delivery Time Varies
Refill Process Yearly a new application with new documentation
Limit Varies
Re-application Once a year new application required. Financial documentation may be requested any time
   

Additional Information

Patient must sign the enrollment form to give the program permission to access their financial information in order to determine eligibility.

Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.

Updated February 09, 2021


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

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • amlodipine benzoate oral suspension (Katerzia) Oral Suspension
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
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

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

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.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.

Updated April 26, 2021