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 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

 

Patient Assistance Applications

AZ&Me Prescription Savings Program with Med D Application

 

Brand Name Medications Covered

 
  • Arimidex tablet
  • Kombiglyze XR tablet; extended release
  • Bevespi Aerosphere
  • Lynparza
  • Brilinta tablet
  • Movantik tablet
  • Bydureon Pen
  • Onglyza tablet
  • Bydureon vial; subcutaneous; extended release
  • Pulmicort Flexhaler powder; inhalation
  • Byetta pen
  • Symbicort aerosol; inhalation
  • Daliresp tablet
  • Symlin injection; subcutaneous
  • Farxiga tablet
  • Synagis
  • Faslodex injection
  • Tagrisso tablet
  • Imfinzi
  • Tudorza Pressair powder; inhalation
  • Iressa
  • Xigduo XR tablet; extended release
 

Generic Name

 
  • aclidinium bromide powder; inhalation
  • gefitinib
  • anastrozole tablet
  • glycopyrrolate/formoterol fumarate
  • budesonide powder; inhalation
  • metformin/saxagliptin tablet; extended release
  • budesonide/formoterol fumarate dihydrate aerosol; inhalation
  • naloxegol oxalate tablet
  • dapagliflozin propanediol/metformin tablet; extended release
  • olaparib
  • dapagliflozin tablet
  • osimertinib tablet
  • durvalumab
  • palivizumab
  • exenatide pen
  • pramlintide acetate injection; subcutaneous
  • exenatide synthetic
  • roflumilast tablet
  • exenatide synthetic vial; subcutaneous; extended release
  • saxagliptin tablet
  • fulvestrant injection
  • ticagrelor tablet
 

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