| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 3. Scroll down to see them all. |
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AZ&Me Prescription Savings Program for people without insuranceThis program provides brand name medications at no or low cost |
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Provided by: AstraZeneca Pharmaceuticals |
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PO Box 222178 TEL: 800-292-6363 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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AZ&Me Prescription Savings Program Application |
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AZ&Me Prescription Savings Program Application (Spanish) |
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AZ&Me Prescription Savings Program Application for Specialty Care Products |
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AZ&Me Prescription Savings Program Application for Specialty Care Products (Spanish) |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| 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. |
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| 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 3. Scroll down to see them all. |
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AZ&Me Prescription Savings Program for people with Medicare Part DThis program only helps people enrolled in Medicare Part D |
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Provided by: AstraZeneca Pharmaceuticals |
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PO Box 222178 TEL: 800-292-6363 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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AZ&Me Prescription Savings Program with Med D Application |
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AZ&Me Prescription Savings Program with Med D Application (Spanish) |
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AZ&Me Prescription Savings Program with Med D Application for Specialty Care Products |
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AZ&Me Prescription Savings Program with Med D Application for Specialty Care Products (Spanish) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Contact program for details. | ||
| Those with Part D Eligible? | Required | ||
| Income | Varies | ||
| Diagnosis/Medical Criteria | Not required | ||
| US Residency Required? | Yes | ||
Application |
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| 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 |
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| 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 |
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| Eligibility determined on a case-by-case basis. |
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| Updated September 17, 2021 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 3. | |||
Patient Access Network Foundation (PAN)This is a copay assistance program |
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Provided by: Patient Access Network Foundation |
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TEL: 866-316-7263FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Patient Access Network Foundation (PAN) Application: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 | FDA Approved Diagnosis - See Program Website for Details | ||
| US Residency Required? | Must reside and receive treatment in US | ||
Application |
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| 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 |
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| 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 |
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| *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. |
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| Updated September 27, 2021 | |||
