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SYMBICORT® (budesonide/formoterol fumarate dihydrate) Inhalation Aerosol
SYMBICORT for Asthma

For patients 12 years and older whose asthma is not well controlled on a long-term asthma medicine or whose disease severity warrants.

SYMBICORT $25 Guarantee Program*

New and current eligible commercially insured patients pay no more than $25 for each prescription, INCLUDING THOSE WITH RESTRICTIONS ON PRESCRIPTION BENEFIT COVERAGE.*


NEW PATIENTS MAY ALSO BE ELIGIBLE TO RECEIVE THEIR FIRST FILL FREE.

To start saving, simply print this offer and present it to your pharmacist, along with a valid prescription.* 

*Subject to eligibility rules below; restrictions apply.

Print Savings Offer

ELIGIBILITY

You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription, or you are not insured and are responsible for the cost of your prescriptions.

Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs or TriCare, and patients who are Medicare eligible and enrolled in an employer sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees.

If you are enrolled in a state or federally funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient.

This offer is not insurance, is restricted to residents of the United States and Puerto Rico, and to patients over 12 years of age. This offer is not valid for mail order.

TERMS OF USE

Eligible commercially insured patients with a valid prescription for SYMBICORT® (budesonide/formoterol fumarate dihydrate) who present this savings card at participating pharmacies will pay $25 per 30 day supply (1 inhaler) if their out-of-pocket cost is more than $25. New commercially insured patients will receive 100% off their out-of-pocket cost for the first inhaler. If you pay cash for your prescription, you will receive up to $100 in savings on your out-of-pocket costs that exceed $25 for each prescription. This offer is good for 12 uses and each inhaler counts as 1 use. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Card expires on 12/31/2015. If you have any questions regarding this offer, please call 1-866-421-2848.

For Massachusetts residents only, this offer will expire on July 1, 2015.

Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed or restricted. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer.

AstraZeneca reserves the right to rescind, revoke, or amend this offer, eligibility and terms of use at any time without notice. This offer is not conditioned on any past, present or future purchase, including refills. Offer must be presented along with a valid prescription for SYMBICORT® at the time of purchase.

If your commercial insurance plan does not cover SYMBICORT, use of this offer permits your healthcare provider or pharmacy to share limited information with certain AstraZeneca vendors to determine if additional resources may be available to you; and to act on your behalf to initiate any processes that may be necessary to access these resources.

BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

Pharmacist Instructions for a Patient With an Eligible Third Party Payer: For Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due to Therapy First Plus as a Secondary Payer COB with patient responsibility amount and a valid Other  Coverage Code of 8. This will reduce the eligible patient's out-of-pocket costs to $25 on a 30-day supply. For Insured/Not Covered Patients: Submit the claim to the primary Third-Party Payer first, if the primary claim submission shows a managed care restriction (step-edit, prior authorization or NDC block), continue the claim adjudication process and submit the balance due to Therapy First Plus as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 3. This will reduce an eligible patient's out-of-pocket costs to $25 on a 30-day supply. Reimbursement will be received from Therapy First Plus.

Pharmacist Instructions for a Cash-Paying Patient: Submit this claim to Therapy First Plus. A valid Other Coverage Code (e.g., 1) is required. The card will cover up to $100 per 30-day supply. Reimbursement will be received from Therapy First Plus.

Valid Other Coverage Code Required. For any questions regarding Therapy First Plus online processing, please call the Help Desk at 1-800-422-5604.

Program managed by PSKW, LLC, on behalf of AstraZeneca.

Important Safety Information About SYMBICORT including Boxed WARNING

SYMBICORT contains formoterol, a long-acting beta2-adrenergic agonist (LABA). LABA medicines such as formoterol increase the risk of death from asthma problems. It is not known whether budesonide, the other medicine in SYMBICORT, reduces the risk of death from asthma problems seen with formoterol.

  • Call your health care provider if breathing problems worsen over time while using SYMBICORT. You may need different treatment
  • Get emergency medical care if:
    • Breathing problems worsen quickly, and
    • You use your rescue inhaler medicine, but it does not relieve your breathing problems

SYMBICORT should be used only if your health care provider decides that your asthma is not well controlled with a long-term asthma control medicine, such as an inhaled corticosteroid, or that your asthma is severe enough to begin treatment with SYMBICORT.

If you are taking SYMBICORT, see your health care provider if your asthma does not improve or gets worse. It is important that your health care provider assess your asthma control on a regular basis. Your doctor will decide if it is possible for you to stop taking SYMBICORT and start taking a long-term asthma control medicine without loss of asthma control.

Children and adolescents who take LABA medicines may have an increased risk of being hospitalized for asthma problems.

SYMBICORT does not replace rescue inhalers for sudden symptoms.

Be sure to tell your health care provider about all your health conditions, including heart conditions or high blood pressure, and all medicines you may be taking. Some patients taking SYMBICORT may experience increased blood pressure, heart rate, or change in heart rhythm.

Do not use SYMBICORT more often than prescribed. While taking SYMBICORT, never use another medicine containing a LABA for any reason. Ask your health care provider or pharmacist if any of your other medicines are LABA medicines.

SYMBICORT can cause serious side effects, including:

  • Pneumonia and other lower respiratory tract infections. People with COPD may have a higher chance of pneumonia. Call your doctor if you notice any of the following symptoms: change in amount or color of mucus, fever, chills, increased cough, or increased breathing problems
  • Serious allergic reactions including rash, hives, swelling of the face, mouth and tongue, and breathing problems
  • Immune system effect and a higher chance of infection. Tell your health care provider if you think you are exposed to infections such as chicken pox or measles, or if you have any signs of infection such as fever, pain, body aches, chills, feeling tired, nausea, or vomiting
  • Adrenal insufficiency. This can happen when you stop taking oral corticosteroid medicines and start inhaled corticosteroid medicine
  • Using too much of a LABA medicine may cause chest pain, increase in blood pressure, fast and irregular heartbeat, headache, tremor, or nervousness
  • Increased wheezing right after taking SYMBICORT. Always have a rescue inhaler with you to treat sudden wheezing
  • Eye problems including glaucoma and cataracts. You should have regular eye exams while using SYMBICORT
  • Lower bone mineral density can happen in people who have a high chance for low bone mineral density (osteoporosis)
  • Slowed growth in children. A child's growth should be checked regularly while using SYMBICORT
  • Swelling of blood vessels (signs include a feeling of pins and needles or numbness of arms or legs, flu like symptoms, rash, pain or swelling of the sinuses), decrease in blood potassium and increase in blood sugar levels

Common side effects in patients with asthma include nose and throat irritation, headache, upper respiratory tract infection, sore throat, sinusitis, stomach discomfort, flu, back pain, nasal congestion, vomiting, and thrush in the mouth and throat.

Approved Uses for SYMBICORT

SYMBICORT 80/4.5 and 160/4.5 are medicines for the treatment of asthma for people 12 years and older whose doctor has determined that their asthma is not well controlled with a long-term asthma control medicine such as an inhaled corticosteroid or whose asthma is severe enough to begin treatment with SYMBICORT. SYMBICORT is not a treatment for sudden asthma symptoms.

Please see full Prescribing Information and Medication Guide and discuss with your doctor.

Talk to your doctor about prescription SYMBICORT.

Read Prescribing Information, including Boxed WARNING, with Medication GuideAdobe PDF (PDF — 551 KB)

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch or call 1-800-FDA-1088.

FlagThis site is intended for US consumers only.

The information on this Web site should not take the place of talking with your doctor or health care professional. If you have any questions about your condition, or if you would like more information about SYMBICORT, asthma, or COPD, talk to your doctor or pharmacist. Only you and your doctor can decide if SYMBICORT is right for you.