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  • Bayer Healthcare Patient Assistance Program Annual Income Form

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Medications listed below, for those in need, who have no prescription drug coverage and limited financial resources. All applications are reviewed on a case-by-case basis. Bayer reserves the right to make a separate, independent determination of patient eligibility and to modify or discontinue the Bayer HealthCare Patient Assistance Program, at any time, without notice. Medication: cc () 30mg cc () 60mg cc () 90mg tablets (Drospire.

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Bayer is committed to helping you with insurance, financial or affordability challenges. Eligible patients may pay as little as $0 and save up to $20,000 per year. Patients who are enrolled in any type of government insurance or reimbursement programs are not eligible.

Eligibility Requirements You do not have public or private insurance that helps to pay for your prescription medications. You have a yearly income of less than ~250% of the Federal Poverty Level: $28,725 or less for a single person. $38,775 or less for a family size of two.

You may be eligible if you meet the following criteria: 1. You have an annual household income* at or below: $35,000 for a single person $48,000 for a family of two $60,000 for a family of three $70,000 for a family of four $80,000 for a family of five * Income limits may be higher in Alaska and Hawaii.

Patient must be enrolled in Medicare Part D, have an income at or below $35,000 as an individual or $48,000 as a couple and be taking an eligible AstraZeneca medicine.

Sanofi Patient Connection® is a program (the “Program”) to help you get access to the medications and resources you need at no cost. Patient Assistance Connection is part of the Program that provides select Sanofi prescription medications and vaccines, at no cost, if you meet certain eligibility requirements.

Those who may qualify must be at least 18 years of age or older, a resident of the 50 United States, the District of Columbia, Puerto Rico, Guam, or the USVI, and demonstrate a financial need with a total annual adjusted gross income of $100,000 or less.

Financial criteria for patient assistance In order to meet the financial eligibility criteria for receiving Sanofi medication at no cost, you must have an annual household income of ≤400% of the current Federal Poverty Level.

Formerly offered at 400 percent of the FPL, this expansion will mean an individual with an income at or below $60,700, or a family of four with a household income of about $125,500 may qualify for its free prescription drug program. For information please visit .TakedaHelpAtHand.com.

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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232