AZ&Me™ Prescription Savings Program for people without insurance

The AZ&Me™ 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.

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.

Contact Information:

AZ&Me Prescription Savings Program

Phone: (800) 292-6363

Fax: (800) 961-8323

How to Apply:

Select one of the links below to download the application or go to the program site for more information on how to apply. Once you fill out your application, send it to the address on the application. Remember not to send program applications to the PPA.


Patient applications are evaluated on a case-by-case basis by the Program. Eligibility is based on income levels and absence of private prescription insurance, third-party coverage, or participation in a public program including the Medicare Limited-Income Subsidy. Income eligibility is based on levels at or below $35,000 for an individual; $48,000 for a couple; $60,000 for family of three; $70,000 for a family of four. The Program requires proof of of income and US residency (Social Security #, work visa # or green card #). Patients approved into the Program will receive an acceptance letter and should receive their shipment of product within 1-2 weeks. Patients denied to the program will receive a denial letter if the individual does not meet the eligibility guidelines of the Program. Enrollment is for 12 months with reapplication at month 10.

Are you eligible?
You may be eligible if you meet the following criteria:

1. You have an annual household income* at or below:
$35,000 for a single person
$48,000 for a family of two
$60,000 for a family of three
$70,000 for a family of four
$80,000 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
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™ 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 up to a 90 day supply of 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).

Other information:

If approved, a three-month supply of the medication is sent directly to the patient's home or other designated location with the exception of Seroquel, Faslodex, and Zoladex from the Program mail-order fulfillment pharmacy. Refills can be requested by the patient or prescribing physician. With the shipment, patient receives instructions on how to request next supply of medication. Patient/family members/physician can obtain information about the Program by calling 1-800-AZandMe (292-6363). An online application is available and can be completed at 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 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 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 898 Somerville, NJ 08876 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.

Product(s) covered by program:

PULMICORT Flexhaler®
Xigduo XR