Prescription Assistance Programs and Medical Product Discounts

To help determine potential eligibility for any of the assistance programs described on the access2wellness Web site, please answer the following questions. (If you are a caregiver inquiring about assistance on behalf of the person you care for, please provide that person's information below.) All questions require a response.

Please click the form Back button and select medication


Where is your residence? Please complete the question Where is your residence?

How old are you? Please complete the question How old are you?

Are you eligible for Medicare Part B and/or Part D? Please complete the question Are you eligible for Medicare Part B and/or Part D?

Do you have any prescription drug coverage (such as Medicaid, Medicare Part D, and/or private insurance)? Please complete the question Do you have any prescription drug coverage (such as Medicaid, Medicare Part D, and/or private insurance)?

How many family members are legally dependent on your household's income? Include yourself, your spouse, your children and any other persons for whom you are legally financially responsible. Please complete the question How many family members are legally dependent on your household's income? Include yourself, your spouse, your children and any other persons for whom you are legally financially responsible.

What is your family's annual gross income? Annual gross income is all pre-tax income received within a calendar year, excluding nontaxable income. Please enter the amount in U.S. dollars. (e.g., 30000.00) Please complete the question What is your family's annual gross income? Annual gross income is all pre-tax income received within a calendar year, excluding nontaxable income. Please enter the amount in U.S. dollars. (e.g., 30000.00)