GENERAL MEDICATIONS
Apply online (must complete all)
- Patient financial profile (dated within 6 months of request)
- Kidney patient prescriptions form
- Copy of pharmacy insurance cards - upload file
For paper applications:
Download form PDFs
Upload completed PDFs
Don't forget to include a copy of the pharmacy insurance cards
For Medication Renewal:
- Medication renewal application (after 3 months of assistance)
- If changes to any forms above (Pharmacy coverage, financial profile, pharmacy insurance cards, etc.) – upload file
- Upload documentation of AHCCCS denial and pharmaceutical company assistance program denials - upload file
- Upload documentation of the status of Health Insurance Marketplace applications or other coverage opportunities - upload file