Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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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 222178
Charlotte, NC 28222

TEL: 800-292-6363


Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

AZ&Me Prescription Savings Program Application

AZ&Me Prescription Savings Program Application (Spanish)

AZ&Me Prescription Savings Program Application for Specialty Care Products

AZ&Me Prescription Savings Program Application for Specialty Care Products (Spanish)

 

Medications

  • aclidinium bromide inhalation powder (Tudorza Pressair) Inhalation Powder
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income Varies
Diagnosis/Medical Criteria Not required
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient or Fax in prescription
Applicant's Action Complete section, sign, attach insurance information
Decision Communicated Patient and Doctor are 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 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.

Eligibility determined on a case-by-case basis.

Updated September 17, 2021


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

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 222178
Charlotte, NC 28222

TEL: 800-292-6363


Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

AZ&Me Prescription Savings Program with Med D Application

AZ&Me Prescription Savings Program with Med D Application (Spanish)

AZ&Me Prescription Savings Program with Med D Application for Specialty Care Products

AZ&Me Prescription Savings Program with Med D Application for Specialty Care Products (Spanish)

 

Medications

  • aclidinium bromide inhalation powder (Tudorza Pressair) Inhalation Powder
 

Eligibility Requirements   

Insurance Status Contact program for details.
Those with Part D Eligible? Required
Income Varies
Diagnosis/Medical Criteria Not required
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient or Fax in prescription
Applicant's Action Complete section, sign, attach insurance information
Decision Communicated Patient and Doctor are 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.

Updated September 17, 2021