| |
AZ&Me Prescription Savings Program for People Without Insurance
|
PO Box 66551
St. Louis, MO 63166-6551
Phone
:
800-424-3727
Fax:
(800)961-8323
|
|
Eligibility
|
| > |
The patient may have isnurance and an income at or below $35,000 for an individual; $48,000 for a couple; $60,000 for a family of three; $70,000 for a family of four. The patient must also be a US resident or have a valid visa or is a green card holder. Patients who are eligible for Medicare Part D but have not enrolled may still eligible for this program. The application for this program and the AstraZeneca Cancer Support Network Patient Assistance Program is the same and says 'Application for Free AstraZeneca Medicines' on the upper left side.People who are in Medicare and may be eligible for the Limited Income Subsidy can apply.However if they are accepted into the LIS, they are no longer eleigible for the AZ& ME program. |
| Who Can Apply
|
| > |
Anyone requesting assistance can call to request a mailed application or download it from the website. |
|
Required
|
| > |
The doctor needs to provide a prescription to the patient. The patient must fill out a section, sign the application and attach proof of income. |
|
Supply
|
| > |
|
|
Ship To
|
| > |
Either Doctor's office or Patient's home |
|
Note
|
| > |
The patient or doctor must contact the company for refills. The patient must reapply once a year. |
| |
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
|
| Pulmicort Respules Inhalation Suspension |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Application Form |
(Requires Acrobat Reader) 
|
| |
|
|