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Program Details
ASTRAZENECA PHARMACEUTICALS
AZ & Me Prescription Savings Program for people without insurance
Nexium
(esmeprazole magnesium)
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| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-800-292-6363 |
Provider Phone: |
|
| Fax: |
1-877-239-0876 |
Website: |
AZ & Me Website |
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| ELIGIBILITY
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| Eligibility
Info: |
Visit AZ&Me website to apply online or to download an application.
Patients must meet qualifying income eligibility criteria.
Patient must be a resident of the US.
Patient must not have prescription drug coverage under a private insurance or government program, or receiving any other assistance to help pay for medicine.
Patients who have experienced a life changing event in the past year are encouraged to apply for the AZ&Me Prescription Savings Program. Examples of this type of event include:
Loss of employment, Change in income, Loss of, or change in, prescription drug coverage,
Marriage or Change in household number. |
| Income at or below: |
Single |
|
% FPL |
| |
Couple |
|
% FPL |
| Federal Poverty Level Calculator |
 |
| Other Income
Requirements: |
For Specialty and Primary products, annual adjusted gross income must be at or below 300% of the Federal Poverty Level.
For Rare Disease product(s), (WAINUA) your annual adjusted gross income must be at or below 500% of the Federal Poverty Level. |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
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|
APPLICATION |
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| Attachments
Required: |
Financial
Prescription
|
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: |
Provider
To get medication delivered directly to the patient's home the following must be written on the prescription - Ship to patient's address: (then put address)
|
| Quantity in
Shipment: |
Varies by product |
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
New prescription every 12 months
|
| Refill Policy: |
Refills can be requested by calling the Program |
| Other Information: |
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Last Updated: 01/30/2024
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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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