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Program Details

ASTRAZENECA PHARMACEUTICALS
AZ & Me Prescription Savings Program for people with Medicare

Symbicort (budesonide/formoterol fumarate dihydrate)
 
CONTACT INFO
Address: 1 Medimmune Way
Gaithersburg, MD 20878
Phone: 1-800-292-6363 Provider Phone:
Fax: 1-877-239-0876 Website: AZ & Me Website
ELIGIBILITY
Eligibility Info:
  • Visit AZ&Me website to apply online or to download an application.
  • Patient must meet qualifying income criteria.
  • Patient must be enrolled in Medicare and are not enrolled in Limited Income Subsidy (LIS).
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: No
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Prescription
    Year-to-date prescription spend history
    Physician License #
    Required:
    State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Providers receive a fax, patient receives letter and phone call
    MEDICATION
    Receives: Medication
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Varies by product
    Delivery Time: 0-1 week
    Re-application Policy: Enrollment is on a calendar year basis, with opportunity to re-enroll.
    Refill Policy: Refills can be requested by calling the Program
    Other Information: Individuals can also apply online, download an application at www.azandme.com.

    Last Updated: 09/27/2023

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.



     

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