Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
Scroll down to see them all.
Updated December 15, 2014
 

Symbicort

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


ALT PHONE: 800-AZandMe
FAX: 800-961-8323
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

AZ&Me Prescription Savings Program with out Med D Application

 

Medications

  • Symbicort Inhaler 80/4mcg, 160/4.5mcg (budesonide/formoterol fumarate dihydrate)
 

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 Not specified
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. $100,000 per year for CAPRELSA. $150,000 per year for MYALEPT.

Eligibility determined on a case-by-case basis.
Contact program for Spanish application.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
Scroll down to see them all.
Updated December 15, 2014
 

Symbicort

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


ALT PHONE:
FAX: 800-961-8323
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

AZ&Me Prescription Savings Program with Med D Application

 

Medications

  • Symbicort Inhaler 80/4.5mcg, 160/4.5mcg (budesonide/formoterol fumarate dihydrate)
 

Eligibility Requirements   

Insurance Status May have Medicare Part D
Those with Part D Eligible? Required
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 or mail
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

At or below $35,000 for an individual, $48,000 for a couple, $60,000 for three, $70,000 for four. $100,000 per year for CAPRELSA. $150,000 per year for MYALEPT.

Eligibility determined on a case-by-case basis.
Contact program for Spanish application.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3. Updated October 17, 2014
 

Symbicort

Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Symbicort Aerosol; Inhalation 80/4.5mcg, 160/4.5mcg (budesonide/formoterol fumarate dihydrate)
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

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.