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

Program 1 of 4.
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Updated March 05, 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

 

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 At or below $35,000 for an individual, $48,000 for a couple, $60,000 for three, 70,000 for four
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

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 eligible for the AZ& Me Prescription Savings Program.

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 4.
Scroll down to see them all.
Updated March 05, 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

 

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 At or below $35,000 for an individual, $48,000 for a couple, $60,000 for three, 70,000 for four
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 Mail or fax
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

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 4.
Scroll down to see them all.
Updated March 04, 2014
Symbicort

HealthWell Foundation Copay Program

This is a copay assistance program.

Provided by: HealthWell Foundation

P.O Box 4133
Gaithersburg, MD 20897-7811

TEL: 800-675-8416


ALT PHONE:
FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website
 

Patient Assistance Applications

Reimbursement Request Form - Copayment Assistance

 

Medications

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

Eligibility Requirements

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Less than 400% of FPL.may qualify. Cost of living in a particular city or state is considered.
Diagnosis/Medical Criteria Medically appropriate condition
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, 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.



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

Program 4 of 4. Updated January 30, 2014
Symbicort

Patient Access Network Foundation

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
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, 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.