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 without insurance

This program provides brand name medications at no or low cost

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 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 Must have no prescription coverage
Those with Part D Eligible? No
Income Varies. *See below for details
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 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 in writing
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 New application yearly
   

Additional Information

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 eligible for the AZ& Me Prescription Savings Program.

At or below $35,000 for an individual, $48,000 for a couple, $60,000 for three, $70,000 for four.
Income for Faslodex, Iressa, Lynparza, and Synagis may be up to $100,000 per year regardless of household size.

Eligibility determined on a case-by-case basis.


Updated July 14, 2017