AZ&Me TM 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. 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. Medicines are mailed to the home or physician's office 5. You or your doctor can request refills. 6. Apply by phone or download an application at www.azandme.com.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 may 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.). 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 at www.azandme.com or call 1-800-AZandMe (292-6363). 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 898, Somerville, NJ 08876OR 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.