The AZ&Me Prescription Savings program for people with Medicare Part D is designed to provide AstraZeneca medicines at no cost to qualified patients enrolled in a Medicare Part D prescription drug coverage plan but who are having difficulty affording their AstraZeneca medicine(s). Highlights 1. AstraZeneca medicines provided at no cost 2. There is NO cost to sign up for this program 3. Enrollment is on a calendar year basis 4. Mailed to the home or physician's office 5. You or your doctor can request refills 6. Convenient online self-service tool to enroll, re-enroll, check enrollment or shipment status or to request a refill Are you eligible? If you are enrolled in Medicare Part D, you may be eligible for the program if you meet the following criteria: 1. Enrolled in Medicare Part D; 2. You are an individual with an annual income at or below $30,000, or if a couple, at or below $40,000; 3. You are taking an eligible AstraZeneca medicine; and Your household has spent at least 3% of annual household income on out-of-pocket costs on prescription medicines within the calendar year How to apply The AZ&Me Prescription Savings program for people with Medicare Part D offers an easy application process that can help you receive your AstraZeneca medicines quickly. To apply to the Program: Download the application ( In English | En Espanol), enroll online, or call 1-800-AZandMe (292-6363). Have your doctor's office help you complete the appropriate sections of the application. 1. Include the required financial information and your signature. * Acceptable forms for financial documentation include a copy of last year's federal income tax returns for yourself, your spouse and dependents, a Social Security Benefit Verification Statement or all income statements from jobs (W-2 or 1099) 2. Include your most recent Explanation of Benefits (EOB) statement from your Medicare Part D plan provider or a print-out of your year-to-date prescription spending history from your pharmacy. 3. Include a valid prescription for your AstraZeneca medicine(s) from your doctor. 4. Mail the completed application, financial information, year-to-date prescription spend history, and prescription to: AZ&Me Prescription Savings Programs PO Box 66551 St. Louis, MO 63166-6551 OR Fax: 1-800-961-8323 If you have questions about the application process, or to learn more about whether or not you or a family member may qualify for this program, call 1-800-AZandMe (292-6363), Monday through Friday, 8:00 AM-6:00 PM EST.