The AZ and Me Prescription Savings Program offers financial assistance to eligible patients, helping them access AstraZeneca medications at reduced costs or for free. This program is designed to support uninsured individuals and those on Medicare who face challenges affording their prescribed treatments. By completing the AZ and Me application form, patients can determine their eligibility and gain access to essential medications through a streamlined process. The program aims to bridge the gap in healthcare affordability, ensuring that necessary treatments remain accessible to those in need.
1.1 Overview of the AZ and Me Application Form
The AZ and Me application form is a straightforward document designed to help patients apply for financial assistance to access AstraZeneca medications. The form requires basic patient information, including date of birth and gender, and must be completed in blue or black ink with clear handwriting. Once filled out, it should be signed and faxed to 1-877-239-0867 along with the provider form. The process ensures eligibility determination efficiently. Patients can download the form from the official website or contact support for assistance. This step is crucial for accessing program benefits.
1.2 Importance of the AZ and Me Program
The AZ and Me program plays a vital role in making AstraZeneca medications more affordable for individuals who struggle with healthcare costs. It provides financial assistance to uninsured patients and those on Medicare, ensuring they can access necessary treatments without financial burden. By offering free or reduced-cost medications, the program helps improve health outcomes and reduces disparities in healthcare access. This initiative underscores AstraZeneca’s commitment to supporting vulnerable populations and enhancing their quality of life through affordable care.
Eligibility Criteria
Eligibility for the AZ and Me program is based on factors such as income, insurance status, and residency. Citizenship is not required, but applicants must be U.S. residents.
2.1 Overview of Eligibility Requirements
Eligibility for the AZ and Me program is determined by income, insurance status, and residency. Applicants must be U.S. residents, though citizenship is not required. Income limits are based on household size and federal poverty guidelines. Patients without prescription drug coverage or those on Medicare may qualify. The program primarily assists uninsured individuals and Medicare beneficiaries facing financial challenges in affording AstraZeneca medications. Meeting these criteria ensures access to necessary treatments at reduced costs or free of charge.
2.2 Income Requirements for the Program
The AZ and Me program has specific income requirements to ensure assistance reaches those in need. Eligibility is typically based on household income relative to federal poverty guidelines. Applicants must provide proof of income, such as tax returns or pay stubs. Income limits vary by household size and are adjusted annually. The program aims to support individuals who cannot afford their medications, ensuring they receive necessary treatments without financial hardship. Meeting these income criteria is essential for qualification.
2.3 Insurance Status and Eligibility
Eligibility for the AZ and Me program is primarily aimed at uninsured individuals and Medicare beneficiaries who struggle to afford their medications. Applicants must provide detailed information about their insurance status. Those without insurance are prioritized, while Medicare patients facing high out-of-pocket costs may also qualify. Commercially insured patients may be eligible if they meet specific income criteria and demonstrate a need for financial assistance. The program does not cover patients with government-sponsored insurance plans, except for Medicare. Insurance details must be submitted to determine eligibility accurately.
2.4 Residency Requirements
To be eligible for the AZ and Me program, applicants must be residents of the United States. Citizenship is not required, but proof of residency may be requested. The program is designed to assist individuals within the U.S. who lack insurance or face financial challenges in affording AstraZeneca medications. Applicants must provide a valid U.S. address to qualify. This requirement ensures that the program’s benefits are directed toward individuals residing within the country, aligning with its mission to support domestic healthcare access. Residency documentation may include a government-issued ID or utility bills.
Required Documents
Required documents include proof of income, residency, and insurance status. A completed provider form is necessary, and both forms must be signed and faxed together.
3.1 List of Required Documents for Application
To complete the AZ and Me application, you will need to provide proof of income, proof of residency, and insurance status documentation. A signed and dated provider form is also required. Additional documents may include identification, such as a valid government-issued ID, and any relevant medical records. Ensure all forms are completed in black or blue ink and that all sections are filled out clearly. Incomplete or unsigned forms may delay processing. Fax all documents together to the specified number to ensure eligibility is determined promptly.
3.2 Signature Requirements
The AZ and Me application requires the patient’s or legal representative’s signature, along with the healthcare provider’s signature. Both signatures must be original and dated. The form must be completed in black or blue ink to ensure readability. Unsigned or incomplete forms will not be processed. The provider must also include their contact information and professional details. Once signed, the form should be faxed to the designated number along with all required documents. Ensure all signatures are clear and legible to avoid delays in eligibility determination.
Application Process
The AZ and Me application process involves completing the form, providing required documents, and submitting it via fax or online. Ensure all sections are filled accurately.
4.1 Step-by-Step Guide to Completing the Application
Visit the official AZ and Me website to download the application form or access it online.
Fill in all required fields, including patient and provider information, using blue or black ink.
Ensure all sections are completed accurately and circles are filled in fully.
Sign and date the form as required.
Gather any additional documentation, such as proof of income or residency.
Submit the completed application via fax to 1-877-239-0867 or through the online portal.
Retain a copy for your records and await confirmation of eligibility.
4.2 Online Application Process
Visit the official AZ and Me website at www.azandmeapp.com to access the online application. Create an account or log in if already registered. Fill out the application form carefully, ensuring all required fields are completed. Upload any necessary documentation, such as proof of income or insurance status. Review and submit the application digitally. Once submitted, you will receive a confirmation. Processing typically begins immediately, and eligibility determinations are made within a few days. For assistance, call 1-800-292-6363, available Monday through Friday, 9 AM to 6 PM ET.
4.3 Paper Application Process
Download or print the AZ and Me application form from the official website. Complete the form using blue or black ink, ensuring all sections are filled legibly. Attach required documents, such as proof of income and insurance status. Mail the completed application to the provided address. Include a stamped envelope for any necessary correspondence. Processing begins upon receipt, and eligibility is determined within a few weeks. For assistance, call 1-800-292-6363, available Monday through Friday, 9 AM to 6 PM ET. Ensure all information is accurate to avoid delays.
4;4 Provider Form Submission
The provider form must be completed by the patient’s healthcare provider, detailing medical eligibility and treatment specifics. Ensure all sections are filled accurately, including the patient’s condition and prescribed medication. Once completed, the provider should fax the form to 1-877-239-0867. Both the patient and provider forms must be received for eligibility review. For any questions regarding the provider form, contact AZ and Me at 1-800-292-6363. Timely submission ensures prompt processing of the application.
Submission Methods
Submit your completed application via fax to 1-877-239-0867, mail, or digitally through the official AZ and Me website. Both forms must be received for processing.
5.1 Fax Submission
To submit your application via fax, send the completed forms to 1-877-239-0867. Ensure both the patient and provider forms are included. Use blue or black ink, and fill in all sections completely. Sign and date the forms before faxing. This method ensures quick processing. For assistance, call 1-800-292-6363, available Monday through Friday. Fax submissions are processed upon receipt, so double-check all details before sending. This method is efficient for those preferring traditional submission.
5.2 Mail Submission
Mail your completed application to the address provided on the form. Ensure all sections are filled using blue or black ink, and both patient and provider forms are included. Sign and date the application before mailing. Attach any required documents, such as proof of income or residency. Use certified mail for tracking. Processing begins upon receipt. Mailing is a reliable option for those who prefer not to fax. Address: P.O. Box 32820, Phoenix, AZ 85023-2820. Allow 2-3 weeks for processing after mailing.
5.3 Digital Submission
Submit your application digitally through the official AZ and Me website; Visit www.azandmeapp.com and follow the online submission instructions. Upload required documents in PDF or Word format. Ensure all fields are completed accurately. Once submitted, you will receive a confirmation email. Digital submission is a fast and secure option, reducing processing time. Applications are typically processed within 7-10 business days. For assistance, call 1-800-292-6363, Monday-Friday, 9 AM-6 PM ET;
Financial Assistance Programs
AZ and Me offers financial assistance to eligible patients, providing free or reduced-cost AstraZeneca medications. The program supports uninsured individuals and Medicare patients facing financial challenges.
6.1 Overview of the AZ and Me Prescription Savings Programs
The AZ and Me Prescription Savings Programs are designed to provide eligible patients with access to AstraZeneca medications at no cost or reduced prices. These programs are tailored for uninsured individuals and Medicare patients who struggle to afford their prescribed treatments. By completing the AZ and Me application form, patients can determine their eligibility and enroll in the program. The initiative aims to ensure that necessary medications are accessible to those in need, bridging the financial gap in healthcare costs. This program is part of AstraZeneca’s commitment to improving patient outcomes through affordable solutions.
6.2 Benefits of the Program
The AZ and Me Prescription Savings Programs offer significant benefits, including access to AstraZeneca medications at no cost or reduced prices. Eligible patients, such as those without insurance or on Medicare, can receive essential treatments affordably. The program eliminates financial barriers, ensuring patients can maintain their health without the burden of high medication costs. Additionally, the streamlined application process and dedicated support team make it easier for patients to navigate and enroll, providing peace of mind and improved access to necessary care.
Special Programs
AZ and Me offers special programs like SYNAGIS and Specialty Products applications, providing tailored support for specific medications. These programs ensure patients receive necessary treatments affordably.
7.1 SYNAGIS Application Process
The SYNAGIS application process is designed for patients requiring palivizumab, particularly high-risk infants. A separate application form is required for SYNAGIS, available on the AZ and Me website. Patients or their representatives must complete the form, ensuring all necessary details are included. The application should be signed and faxed to 1-877-239-0867 along with the provider form. Eligibility is determined upon receipt of both forms. For assistance, applicants can contact AZ and Me at 1-800-292-6363. This program helps ensure access to critical medication for vulnerable populations.
7.2 Specialty Products Application
For specialty products like CALQUENCE® (acalabrutinib) and FASENKITM (benralizumab), a dedicated application form is required. Patients must use the AZ and Me Application for Specialty Products, available on the program’s website. The completed form should be signed and faxed to 1-877-239-0867. This ensures proper processing and eligibility determination. Applicants can contact AZ and Me at 1-800-292-6363 for assistance. This streamlined process helps patients access necessary specialty medications through the program’s financial assistance offerings.
Provider Forms
The AZ and Me Provider Form must accompany the patient’s application to determine eligibility. Both forms should be faxed to 1-877-239-0867 for processing. Assistance is available at 1-800-292-6363.
8.1 AZ and Me Provider Form Requirements
The AZ and Me Provider Form must be completed by a healthcare provider and signed. It requires detailed patient and medication information. The form ensures eligibility verification for financial assistance. Both the patient’s application and the provider form must be submitted together. Fax the completed forms to 1-877-239-0867. For assistance, call 1-800-292-6363, Monday-Friday, 9 AM-6 PM ET. Ensure all sections are filled accurately for timely processing. Incomplete forms may delay eligibility determination. Providers play a crucial role in helping patients access necessary medications through this program.
Deadlines and Processing Times
Applications are processed upon receipt. Fax completed forms to 1-877-239-0867. Processing typically takes 2-3 weeks. Ensure all documents are complete to avoid delays in determination.
9.1 Application Deadlines
There are no strict deadlines for submitting the AZ and Me application form. However, timely submission is encouraged to ensure uninterrupted access to medications. Applications can be faxed to 1-877-239-0867 at any time. Processing typically begins upon receipt of completed forms. Incomplete applications may delay eligibility determination. It is recommended to submit all required documents together to expedite the review process. For any questions or concerns about deadlines, contact AZ and Me support at 1-800-292-6363, Monday through Friday, 9 AM to 6 PM ET.
9.2 Processing Time for Applications
The AZ and Me application processing time typically ranges from 7 to 10 business days after receipt of completed forms. Delays may occur if applications are incomplete or additional documentation is required. Once eligibility is determined, patients receive notification, and program benefits are applied. For status updates or concerns, contact AZ and Me support at 1-800-292-6363, Monday through Friday, 9 AM to 6 PM ET. Ensuring all required documents are submitted together helps expedite the review process and allows patients to access necessary medications without unnecessary delays.
FAQs
- What is the AZ and Me Program? It helps eligible patients access AstraZeneca medications at reduced costs.
- How do I apply? Complete the application form, sign, and fax it to 1-877-239-0867 with the provider form.
- What documents are needed? Proof of income, residency, and insurance status.
- Who is eligible? Uninsured or Medicare patients struggling to afford medications.
- Where can I find help? Call 1-800-292-6363 for assistance.
10.1 Common Questions About the Application Process
- How do I submit the application? Fax the completed form to 1-877-239-0867 along with the provider form.
- What documents are required? Proof of income, residency, and insurance status must be included.
- Can I apply online? Visit www.azandmeapp.com to enroll digitally or download the application form.
- Am I eligible if I have Medicare? Yes, Medicare patients who struggle to afford medications may qualify.
- How long does processing take? Processing times vary, but completed applications are reviewed promptly.
- Where can I get help? Call 1-800-292-6363 for assistance or questions about the application process.
Troubleshooting Common Issues
Common issues with the AZ and Me application include incomplete forms, incorrect fax numbers, or delayed processing. Ensure all required fields are filled and documents are attached. Verify the fax number for submissions is 1-877-239-0867. If processing is delayed, confirm receipt of both the patient and provider forms. For rejected applications, review eligibility criteria and resubmit with corrected information. Contact AZ and Me support at 1-800-292-6363 for assistance with unresolved issues or clarification on application requirements.