Are you currently taking any AstraZeneca medications and having trouble affording them? If you are, we may be able to help. This site will guide you through the AZ&Me application process to see if you are eligible for the program.
Fax Your Application from
your Doctor’s Office:
For BRILINTA® (ticagrelor):
For SYNAGIS® (palivizumab) or IMFINZI™ (durvalumab):
For FASLODEX® (fulvestrant), IRESSA® (gefitinib), LYNPARZA™ (olaparib), or TAGRISSO® (osimertinib):
For all other products:
NOTE: Faxed applications MUST be sent from your doctor’s office in order for us to process your prescription.
3 Ways to Apply
Begin the Pre-Screening Process
Our programs offer to provide you with AstraZeneca medications at no cost, but we need to determine if you are eligible first.
Helpful Resources & Downloads
Find answers to your questions and downloadable resources that help you prepare and apply for our programs.
Download an Application
You can choose to download a blank application and then fill out the form, or fill your information directly into the PDF before downloading.
If you are seeking assistance for SYNAGIS® (palivizumab),
click here to download an application.