The AZ&Me TM Prescription Savings program for people without insurance is designed to provide AstraZeneca medicines at no cost to qualified patients. This patient prescription assistance program can help patients who do not have prescription drug coverage and who meet other eligibility criteria. Highlights 1. AstraZeneca medicines provided at no cost 2. There is NO cost to sign up for the program 3. Once accepted, you remain enrolled for up to one year. At the end of that year you can reapply. 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? You may be eligible if you meet the following criteria: 1. You have an annual household income* at or below: $30,000 for a single person $40,000 for a family of two $50,000 for a family of three $60,000 for a family of four $70,000 for a family of five * Income limits might be higher in Alaska and Hawaii. 2. You do not receive prescription drug coverage under any private insurance or any other coverage that provides assistance to help pay for medicines, such as: Employer furnished or private prescription drug coverage VA or Military Benefits Medicaid Medicare Part A Medicare Part B (covers some injectable medicines) Medicare Part D* State assistance program for medicines (SPAP, SCHIP, PACE, etc.) * Individuals enrolled in Medicare Part D may be eligible for the AZ&Me TM Prescription Savings program for people with Medicare Part D What if you are enrolled in Medicare and Qualify for the Limited Income Subsidy? Patients who are in Medicare and may be eligible for the Limited Income Subsidy ("LIS") can apply to the AZ&Me TM Prescription Savings program for people without insurance. When you apply to this program, you will receive information and one-on-one education designed to help with the LIS application process. During the processing of your LIS application, you may be temporarily enrolled in the AZ&Me Prescription Savings Program. This means you could receive your AstraZeneca medicine(s) from the Program while you wait for your LIS application results. Once the Social Security Administration confirms that you have qualified for the LIS, you are no longer eligible for the AZ&Me Prescription Savings program because you will have access to affordable, comprehensive coverage. You will no longer receive AstraZeneca medicines through the AZ&Me Prescription Savings Program. If the Social Security Administration denies your application for LIS, our assistance specialists can help you complete the enrollment process for the AZ&Me Prescription Savings program for people without insurance, so you can continue receiving your AstraZeneca medicine(s). What if you do not qualify for the Limited Income Subsidy and are not enrolled in Medicare Part D? You may apply to the AZ&Me Prescription Savings program for people without insurance and get one-on-one support to help you identify and access health and prescription drug coverage and services for which you may qualify. If you have not enrolled in a Medicare Part D plan, and if you meet the other eligibility criteria, you may be eligible for the AZ&Me Prescription Savings program for people without insurance. How to apply The AZ&Me Prescription Savings program for people without insurance offers an easy application process that can help you receive your AstraZeneca medicines quickly. To apply to the Program: 1. 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. 2. 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) 3. If you are not a US citizen, you must also provide a valid US Green Card number or a confirmation letter from the government stating that you have applied for a US Green Card or a Work Visa number. 4. Include a valid prescription for your AstraZeneca medicine(s) from your doctor. 5. Mail the completed application, financial information, and prescription(s) 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 TO 6:00 PM EST.