Application Checklist

If you are applying for assistance with SYNAGIS® (palivizumab), please refer to the checklist printed on the application for that product. Click here to download an application for SYNAGIS.

Before you sit down and begin the application process, make sure you have the items on this list. You’ll need:

Financial documentation – acceptable forms include:

  • A copy of the most recent federal income tax returns for yourself, your spouse, and dependents
  • All income statements from jobs last year (W2 or 1099)
  • Social Security Income Yearly Benefits Statement (stating income you received from Social Security in the past year)
  • If your income is zero, a letter explaining your financial situation from a family member, healthcare provider, or yourself.

Your prescription(s) for the AstraZeneca medicine(s) you are taking

Your Social Security Number if you are a US Citizen

If you are not a US citizen, you’ll need one of the following:

  • Green Card Number
  • Work Visa Number

If you’ve experienced recent financial hardship and your financial documentation from last year does not accurately reflect your current situation, you’ll need to include supporting documentation explaining how your circumstances have changed. These forms include:

  • Employer or unemployment office letter
  • A copy of a marriage certificate or divorce decree to explain a change in marital status
  • A copy of a birth or death certificate to explain a change in household number

IMPORTANT PROGRAM UPDATE:

Please note that there has been a change to the eligibility requirements for the AZ&Me™ Prescription Savings program for people with Medicare Part D. Beginning in 2017, in addition to meeting current eligibility criteria patients will also be required to spend 3% of total household income on prescription medicines through a Medicare Part D Prescription Drug Plan during 2017 in order to qualify for the program.

Medicare Part D patients will be required to submit a copy of their Medicare Part D prescription drug plan statement (Explanation of Benefits – EOB), pharmacy receipts or a summary document from a pharmacy indicating total spend on prescriptions in 2017; this total should be at least 3% of household income.

For questions regarding this change, please call 1-800-292-6363.

NOTE: Patients with Medicare Part B coverage may also be eligible. Please call 1-800-292-6363 for more information.