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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

 

Program Applications and Forms

AZ&Me Prescription Savings Program with out Med D Application

 

Medications

  • Symbicort aerosol; inhalation (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 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 October 17, 2016


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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

 

Program Applications and Forms

AZ&Me Prescription Savings Program with Med D Application

 

Medications

  • Symbicort aerosol; inhalation (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 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

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 October 17, 2016


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HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

 HealthWell Foundation Copay Program: Contact program

 

Medications

  • Symbicort (budesonide/formoterol fumarate dihydrate)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated November 18, 2016


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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


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

 Patient Access Network Foundation (PAN) Application: Contact program

Patient Access Network Foundation (PAN) Provider Brochure

Patient Access Network Foundation (PAN) Patient Brochure

 

Medications

  • Symbicort (budesonide/formoterol fumarate dihydrate)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% 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 Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
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

*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.


Updated August 02, 2016


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Symbicort

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Access 360

Provided by: AstraZeneca Pharmaceuticals


TEL: 844-275-2360


FAX: 844-329-2360
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Access 360 Patient Authorization Form (PAF) Oncology

Access 360 Patient Authorization Form (PAF) Oncology (Spanish)

Access 360 Request Form

 

Medications

  • Symbicort aerosol; inhalation (budesonide/formoterol fumarate dihydrate)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Determined case by case
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 from Doctor's office
Doctor's Action Varies
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Access 360 can help identify patient-specific coverage for AstraZeneca medicines. The representatives can create an in-depth report identifying the patient's full coverage and out-of-pocket costs for medical, pharmacy, and home health benefits related to AstraZeneca products.

Contact program for more details: www.myaccess360.com


Updated September 27, 2016