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Eligibility Assessment: Potentially Ineligible
Based on your responses, you may not meet our eligibility requirements.
It appears that your adjusted gross income is over the program guideline. You may be able to apply if you have experienced a change in circumstance that should be considered. Visit Eligibility Requirements to see examples of Change in Circumstances that can be considered.
Before starting the AZ&Me application, make sure you have the following:
AZ&Me Income Guidelines by Product Categoryas of January 26, 2026
Annual Income Limits for
Primary & Specialty Products
300% FPL
Household Size
48 States
Alaska
Hawaii
1
$47,880
$59,850
$55,080
2
$64,920
$81,150
$74,670
3
$81,960
$102,450
$94,260
4
$99,000
$123,750
$113,850
5
$116,040
$145,050
$133,440
6
$133,080
$166,350
$153,030
7
$150,120
$187,650
$172,620
8
$167,160
$208,950
$192,210
Annual Income Limits for
Rare Disease Products
500% FPL
Household Size
48 States
Alaska
Hawaii
1
$79,800
$99,750
$91,800
2
$108,200
$135,250
$124,450
3
$136,600
$170,750
$157,100
4
$165,000
$206,250
$189,750
5
$193,400
$241,750
$222,400
6
$221,800
$277,250
$255,050
7
$250,200
$312,750
$287,700
8
$278,600
$348,250
$320,350
Household income must be at or below
the above income limits
to be eligible for AZ&Me.
Effective January 26, 2026.
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.
Please note: If you live in Alaska or Hawaii, you may still qualify. Click HERE to see the income guidelines for residents in Hawaii and Alaska.
Other options may be available to you on www.AZPatientsupport.com.
Please note: If you live in Alaska or Hawaii, you may still qualify. Click HERE to see the income guidelines for residents in Hawaii and Alaska.
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
