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Eligibility Assessment: Potentially Ineligible
Based on your responses, you may not meet our eligibility requirements.
Typically, insurance covers our products. If your medication is one of AZ&Me’s Specialty or Rare Disease products, you may be able to enroll with Proof of Denial from your insurance. Click HERE to see if your medication is considered a Specialty or Rare Disease product on AZ&Me.
Before starting the AZ&Me application, make sure you have the following:
Information About You (the Patient)
- Name
- Home Address
- Contact Information: Phone Number & Email
- Health Insurance Information
- Household Size
- Adjusted Gross Income
Your adjusted gross household income is the total income for yourself, your spouse, and all dependents in the household. This can be found on your most recent IRS Form 1040, on line 11.
Information About Your Medication
- AstraZeneca Medication Name & Formulation*
- Prescriber's Name
- Prescriber's Office/Facility Name
- Prescriber's Office Address
*For a list of medications available on the AZ&Me Program, click HERE.
Other options may be available to you on www.AZPatientsupport.com.
Other options may be available to you on www.AZPatientsupport.com.
If you would still like to apply, choose the option below that best describes you:
If you would still like to download an application, click HERE.
You may report side effects related to AstraZeneca products 
.
©2026 AstraZeneca. All rights reserved. US-94004; US-99057; US-103769; US-106756; US-112368 Last Updated 5/26
