AstraZeneca (AZ&Me) Patient Assistance Program

Requirements for uninsured applicants

• Applicant must be at or below 300% federal poverty level to qualify
  • View federal poverty guidelines
• If patient has -0- income, a letter can be submitted on their behalf
• Applications are good for 1 year once approved

Requirement for Medicare Part D applicants

• Medicare part D enrollees must have spent 3% of their household income on prescription medications to qualify
• Medicare Part D enrollees are also required to submit a Low Income Subsidy (LIS) denial letter with their application
  • If they have not yet applied, they must apply and be denied before the application can be submitted
• Applications for Medicare part D enrollees are valid until December 31st of current year