Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

AZ&Me Prescription Savings Program for people with Medicare Part D

This program only helps people enrolled in Medicare Part D.

Provided by: AstraZeneca Pharmaceuticals

PO Box 898
Somerville, NJ 08876

TEL: 800-292-6363


FAX: 800-961-8323
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

AZ&Me Prescription Savings Program with Med D Application

 

Brand Name Medications Covered

 
  • Arimidex tablet
  • Lynparza capsule
  • Bevespi Aerosphere
  • Movantik tablet
  • Brilinta tablet
  • Onglyza tablet
  • Bydureon Pen
  • Pulmicort Flexhaler powder; inhalation
  • Bydureon vial; subcutaneous; extended release
  • Symbicort aerosol; inhalation
  • Byetta pen
  • Symlin injection; subcutaneous
  • Daliresp tablet
  • Synagis
  • Farxiga tablet
  • Tagrisso tablet
  • Faslodex injection
  • Tudorza Pressair powder; inhalation
  • Imfinzi
  • Xigduo XR tablet; extended release
  • Iressa
  • Zoladex
  • Kombiglyze XR tablet; extended release
  • Zurampic
 

Generic Name

 
  • aclidinium bromide powder; inhalation
  • glycopyrrolate/formoterol fumarate
  • anastrozole tablet
  • goserelin acetate
  • budesonide powder; inhalation
  • lesinurad
  • budesonide/formoterol fumarate dihydrate aerosol; inhalation
  • metformin/saxagliptin tablet; extended release
  • dapagliflozin propanediol/metformin tablet; extended release
  • naloxegol oxalate tablet
  • dapagliflozin tablet
  • olaparib capsule
  • durvalumab
  • osimertinib tablet
  • exenatide pen
  • palivizumab
  • exenatide synthetic
  • pramlintide acetate injection; subcutaneous
  • exenatide synthetic vial; subcutaneous; extended release
  • roflumilast tablet
  • fulvestrant injection
  • saxagliptin tablet
  • gefitinib
  • ticagrelor tablet
 

Eligibility Requirements   

Insurance Status May have Medicare Part D
Those with Part D Eligible? Required
Income Varies
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes, or have green card or work visa
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail from Doctor's office
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Patient notified
Decision Timeframe Within 2 weeks
   

Medication

Amount/Supply Up to 90 day supply
Sent To Doctor's office or patient's home
Delivery Time Within 5-7 business days
Refill Process Patient or Doctor must contact company
Limit None
Re-application Must re-enroll at end of calendar year
   

Additional Information

Eligibility determined on a case-by-case basis.

*Patients with Medicare Part B coverage may also be eligible. Contact program for details.


Updated July 14, 2017