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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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| Accolate Tablets |
| Arimidex Tablets |
| Atacand HCT |
| Atacand Tablets |
| Brilinta Tablets |
| Crestor Tablets |
| Faslodex Injection |
| Merrem |
| Nexium Capsules |
| Nexium Injection |
| Nexium Oral Suspension |
| Pulmicort Flexhaler |
| Pulmicort Respules Inhalation Suspension |
| Rhinocort Aqua Nasal Spray |
| Seroquel Tablets |
| Seroquel XR Extended Release Tablets |
| Symbicort (No PAP Available) |
| Toprol XL Tablets |
| Vimovo delayed-release tablets |
| Zoladex 10.8 Depot |
| Zomig Nasal Spray |
| Zomig-ZMT Orally Disintegrating Tablets |
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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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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. |
| |
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.
|
| Arimidex Tablets |
| Atacand HCT |
| Atacand Tablets |
| Brilinta Tablets |
| Crestor Tablets |
| Faslodex Injection |
| Merrem |
| Nexium Capsules |
| Nexium for Oral Suspension |
| Nexium Injection |
| Pulmicort Flexhaler |
| Rhinocort Aqua Nasal Spray |
| Seroquel Tablets |
| Seroquel XR Extended Release Tablets |
| Symbicort (No PAP Available) |
| Toprol XL Tablets |
| Vimovo delayed-release tablets |
| Zoladex Implant |
| Zomig Tablets |
| Zomig-ZMT Orally Disintegrating Tablets |
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AstraZeneca Cancer Support Network (AZ CSN)
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PO Box 66551
St. Louis, MO 63166-6551
Phone
:
866-992-9276
Fax:
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below $30,000 for an individual; $40,000 for a couple; $50,000 for a family of three; $60,000 for a family of four. The patient must also be a US resident or have a valid visa or is a green card holder. |
| Who Can Apply
|
| > |
Anyone requesting assistance can call to request a faxed application or download it from the website. |
|
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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Up to a 60-day supply |
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Ship To
|
| > |
Either Doctor's office or Patient's home |
|
Note
|
| > |
Anyone requesting assistance can call to request a faxed application or download it from the website. |
| |
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.
|
| Arimidex Tablets |
| Faslodex Injection |
| Zoladex 1-month Depot |
| Zoladex 3-month Depot |
| Zoladex Depot |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Application Form |
| (Requires Acrobat Reader)
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