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AZ&Me Prescription Savings Program for People with Medicare Part D
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,
Phone
:
800-292-6363
Fax:
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Eligibility
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The patient must have Medicare Part D, and have an income less than or equal to $30,000 for an individual (less than or equal to $40,000 for a couple.) |
| Who Can Apply
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The patient should call for a prescreening or go to the website and apply on line. |
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Required
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The patient must provide information and proof of income. |
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Supply
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The Patient is sent an enrollment kit and a program card that they can use at their local pharmacy to receive their AstraZeneca medications for no more than $25 for a typical 30-day prescription. |
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Ship To
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Patient's home |
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Note
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The patient should call for a prescreening or go to the website and apply on line. |
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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.
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| Pulmicort Flexhaler |
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AZ&Me Prescription Savings Program for People Without Insurance
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PO Box 66551
St. Louis, MO 63166-6551
Phone
:
800-424-3727
Fax:
(800)961-8323
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Eligibility
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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
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Anyone requesting assistance can call to request a mailed application or download it from the website. |
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Required
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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. |
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Supply
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Ship To
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Either Doctor's office or Patient's home |
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Note
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The patient or doctor must contact the company for refills. The patient must reapply once a year. |
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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.
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| Pulmicort Flexhaler |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
:
(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*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. |
| |
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 Flexhaler |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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