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Application for

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Application for
Free AstraZeneca Medicines:
PO Box 222178, Charlotte, NC 28222
How to Complete this Application:
1. Review the information on this page carefully and keep it for your records.
2. Complete pages 3, 4 and 5 of the application.
3. Gather the required documentation listed on page 2.
4. Mail or fax your completed application and required documentation following the instructions on
the next page.
What are the AZ&Me Prescription Savings Programs?
• The AZ&Me Prescription Savings Programs (the Program) are a group of programs offered by AstraZeneca
that allow you to get free medicines if you qualify. It is neither a government program nor an insurance plan
• If you qualify, you may get free AstraZeneca medicine for up to 1 year, depending upon the Program in
which you are enrolled. AstraZeneca will send you an application for renewal once your enrollment ends
• Your medication may be sent to your home or to your doctor’s office
Who is AstraZeneca?
• AstraZeneca is a company that makes prescription medicines
• AstraZeneca has offered prescription savings programs to people who qualify since 1978
The Program can be changed or stopped by AstraZeneca at any time or for any reason.
Do you qualify for the Program?
You may qualify for the Program if:
3 You are a US resident
3 You meet certain household income limits
(visit www.azandmeapp.com or call 1-800-292-6363 or 1-800-AZandMe for details)
3 And one of the following applies:
n You do not have prescription drug coverage that helps pay for your AstraZeneca medicines
n You participate in Medicare Part B or Part D and have spent at least 3% of your total household
income on prescription medicines during the current year
The Affordable Care Act created a marketplace of Health Insurance Exchanges where uninsured individuals
and families are able to purchase healthcare coverage, the cost of which may be subsidized for qualified
enrollees. More information about these plans can be found at www.healthcare.gov.
Please review the checklist on the next page to ensure that your application is complete
and ready for submission.
Application for Free AstraZeneca Medicines
Page 2 of 5
AZ&Me Prescription Savings Program Application Checklist
The following items must be submitted by mail or by fax to complete your application. Keep this
page for your records.
Send ALL the following TOGETHER:
n A completed application, signed and dated by you and your prescriber
Blank applications can be found on www.azandmeapp.com. If you are applying for assistance with
Oncology or Respiratory Biologics products, please use the AZ&Me Application for Specialty Care
Products.
n The completed prescription on page 3 of this application
n If you are a Medicare Part B or Medicare Part D enrollee, please also include:
A copy of your Medicare Part B and/or Medicare Part D Prescription Drug Plan statement
(Explanation of Benefits [EOB]), a pharmacy printout, or a summary document from your pharmacy
indicating the amount you have spent for prescriptions in the current calendar year; this total should
be at least 3% of your income
Please do not send your medical records with your application.
MAIL your completed application, prescription, and Medicare documentation (if applicable) to:
AZ&Me Prescription Savings Program
PO Box 222178
Charlotte, NC 28222
Or
Your doctor’s ofce may FAX your completed application, prescription and required documentation,
with a fax cover sheet. For all non-specialty products: 1-800-961-8323. Applications and
prescriptions not faxed from the doctor’s ofce will be deemed invalid.
Important Information about your Application
Information provided to us will be used to determine possible eligibility for help from another program such
as Medicaid. You may be required to submit documentation supporting that you do not qualify for other
prescription assistance.
For Prescription Rells, call 1-800-292-6363
Once you are enrolled in the Program, your prescriptions can easily be refilled by contacting our phone line
Monday through Friday, 9:00 am – 6:00 pm EST.
Questions? Call 1-800-292-6363 Monday–Friday, 9:00 am to 6:00 pm ET or visit
www.azandmeapp.com
Application for Free AstraZeneca Medicines
Page 3 of 5
Questions? Call 1-800-292-6363 Monday–Friday, 9:00 am to 6:00 pm ET or visit
www.azandmeapp.com
PATIENT INFORMATION:
Please print clearly in blue or black ink. Asterisks indicate required fields.
Primary language spoken:
n English n Spanish n Other:__________________________
Patient Name*: _________________________________________________________________________________________________________
First Middle Initial Last
Date of Birth*: _______/_______/________
(MM/DD/YYYY)
Address*: ____________________________________ City*: ______________________ State*: _______________ Zip*: ________________
n Patient has no current address. (Medication will be shipped to HCP’s office)
Please note: Medications cannot be shipped to Post Office (PO) boxes.
Phone*: ( ______ ) _____________________ Mobile Phone: ( ______ ) ___________________ E-mail: _______________________________
PRESCRIBER INFORMATION: This form will replace all previous prescriptions that may have been sent.
Prescriber Name*: _______________________________________ Phone*: ( ______ ) _____________ Fax*: ( ______ ) _____________________
Address*: _______________________________________ City*: _______________________ State*: ________________ Zip*: _________________
Prescriber E-mail:
________________________________ NPI*: _______________________ State License Number (SLN): ___________________
Office Contact Name*: ____________________ Phone*: ( ______ )___________ Practice Name*: _______________________________________
Medication*: Strength*: Directions*: Quantity*: Refills*:
SHIP MEDICATION TO:
n PATIENT n PRESCRIBER
†
(
†
For Prescribers in Ohio ONLY: Pursuant to OAC 4729-5-10, Ohio prescribers must be approved by the Ohio Board of Pharmacy to be a pick-up station)
Prescriber Signature: ____________________________________________________ Date: _______________________________
NY Prescribers must attach a separate prescription in accordance with NY pharmacy law.
n New Application n Re-enrollment
n Syringe n Pen n Vial n Oral n Other
Please complete prescription in its entirety.
click to sign
signature
click to edit
Program Eligibility Information: Please print clearly in blue or black ink.
INCOME:
What is the total combined household income before taxes? (Include yourself, all adults, and all dependents)
Income Verication: AZ&Me and its authorized third-party agents will use my date of birth and/or additional demographic information as
needed to access my credit information and information derived from public and other sources to estimate my income in conjunction with
the eligibility determination process. As a soft credit inquiry, this option will not impact my credit score. AZ&Me and its authorized third-
party agents reserve the right to ask for additional documents and information at any time.
$_________________________________________ Monthly OR $_________________________________________ Yearly
Number of people in your household: _________________ Number of dependents in your household under 18 years of age:
___________
(Include yourself, all adults, and all dependents)
INSURANCE:
Do you have any form of prescription drug coverage? n Yes n No
If Yes, please check all that apply:
n Employer-furnished or commercial/private drug coverage. Please provide plan name and ID number:__________________________
n VA or Military Benefits n Other Prescription Coverage ________________
n Medicaid Prescription Drug Coverage
n Medicare Part B (medical benefit that covers some prescription medications)
n Medicare Part D (prescription drug coverage). Please provide payer name:__________________________
n Low Income Subsidy
If the requested medication is covered under Medicare Part B or Part D, how much have you spent on prescription medicines during the
current year? $_______________________________
Do you have Medicare supplemental (Medigap) coverage?
n Yes n No
If so, does your supplemental coverage cover your total out-of-pocket cost for your medication? n Yes n No
Application for Free AstraZeneca Medicines
Page 4 of 5
Questions? Call 1-800-292-6363 Monday–Friday, 9:00 am to 6:00 pm ET or visit
www.azandmeapp.com
Application for Free AstraZeneca Medicines
Page 5 of 5
AZ&Me is a trademark of the AstraZeneca group of companies.
©2020 AstraZeneca. All rights reserved. US-37556 2/20
CONSENT:
I GIVE my doctor, AstraZeneca, and the Program administrator and their employees, agents, and contractors
permission to verify my information to make sure it is true and complete; contact me by mail or phone about
the Program and about other products, programs, or services that might interest me or for which I may be
eligible; contact me in order to ensure that I have received the medicines sent by the Program.
I PROMISE that all the information in this application, including all copies of documents proving my income,
is true and complete; I am authorized to sign this application; I do not have any assistance or insurance that
would help pay for my medicines (other than Medicare, if applicable); I will contact the Program if any of my
information about my prescription drug coverage or insurance changes.
I UNDERSTAND that the Program will only use my information to decide if I qualify to participate in the
Program; administer or improve the Program; communicate with insurance plans, including Medicare plans;
share my information with the Centers for Medicare and Medicaid Services.
I UNDERSTAND that I may be required to apply for prescription assistance through a government
assistance program to maintain eligibility in the Program.
I UNDERSTAND that I can call 1-800-292-6363 at any time to withdraw from the Program and/or
cancel my permission to use my information. I can visit www.globalprivacy.astrazeneca.com to review
AstraZeneca’s Privacy Notice.
I UNDERSTAND that the Program can request more information from me at any time; AstraZeneca can
change or stop the Program at any time or for any reason.
I UNDERSTAND that once my information has been disclosed to my doctor, federal privacy laws may no
longer restrict its use or disclosure, but the Program will only use my information as described in this form.
I MAY refuse to sign this authorization form and if I refuse, my eligibility for health plan benefits and
treatment by my healthcare provider will not change, but I will not have access to the Program.
I GIVE the Program, and the Program administrators, permission to contact the person named below with
follow-up questions about my application (this only applies if someone completed this application for you).
This authorization form will be effective for 1 year unless it expires earlier by law or I cancel it in writing. I
have a right to receive a copy of this form after I have signed it.
Signature of Applicant or Parent/Legally Authorized Representative. If patient is a minor,
parent or legally authorized representative should sign here.
Relation to Patient: n Patient n Parent/Legally Authorized Representative of Patient
X_______________________________________Date:_______/_______/________(MM/DD/YYYY)
If someone helped you with this application and you want them to answer questions for you, please give
us their name and phone number:
Helper’s Name:______________________________________Helper’s Phone: ( _____ ) ____________
Questions? Call 1-800-292-6363
Monday–Friday, 9:00 am to 6:00 pm ET
or visit www.azandmeapp.com
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Completed 18 November 2020

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