Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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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


FAX: 800-961-8323
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

AZ&Me Prescription Savings Program Application

 

Medications

  • aclidinium bromide powder; inhalation (Tudorza Pressair) Powder; Inhalation
 

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 November 07, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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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

  • aclidinium bromide powder; inhalation (Tudorza Pressair) Powder; Inhalation
 

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 November 24, 2017


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

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

  • aclidinium bromide (Tudorza Pressair) 
 

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 May 22, 2017