SYMBICORT

SAVINGS OFFER

For new SYMBICORT patients

Pay $0 for Your Next Prescription

This SYMBICORT savings offer is brought to you by .

  • For eligible commercially insured patients

You could get your SYMBICORT prescription filled FREE for up to 12 months—even if you have restrictions on your prescription benefit coverage.

  • For Medicare/Medicaid/ Uninsured patients

You could get your first SYMBICORT prescription (one inhaler) FREE! Just present the free prescription offer to your pharmacist along with a valid prescription for SYMBICORT.

Subject to eligibility rules; restrictions apply.

Breathable-Reg

Sign Up Here to Get Your
SYMBICORT Prescription FREE

with our AZ Helps logo savings program


Please fill out the short form below to get great savings on SYMBICORT. After submitting, you can start using your card right away.


AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. Certain information pertaining to your participation will be shared with AstraZeneca, the sponsor of the Program. The information shared will include the date that you filled the prescription, the quantity of medication dispensed by your pharmacist, and your savings under the Program. AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. If in the future you no longer want to receive these materials, please call 1-800-236-9933.

Please visit www.azprivacynotice.com to review our Privacy Notice.

*Required fields

STEP 1 OF 2: Get Started

 
I am commercially insured I am uninsured or use Medicare/Medicaid
 
Myself Someone I care for
 
 Asthma
 COPD, Emphysema, or Chronic Bronchitis
 None of the above
 
 Yes
 No

STEP 2 OF 2: Enter Your Details

In order to participate in the savings program, please enter your details below.

 
 
 
Male Female
 
 
 
 
 
 
 
 
 

By registering today, you will receive information about SYMBICORT, and may receive information about other respiratory medicines and services related to your condition.

You must be at least 18 years of age.

 Yes, I would also like to receive information in the future about all AstraZeneca products, programs, and services that may be of interest to me.
 

COPD_REG

Sign Up Here to Get Your
SYMBICORT Prescription FREE

with our AZ Helps logo savings program


Please fill out the short form below to get great savings on SYMBICORT. After submitting, you can start using your card right away.


AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. Certain information pertaining to your participation will be shared with AstraZeneca, the sponsor of the Program. The information shared will include the date that you filled the prescription, the quantity of medication dispensed by your pharmacist, and your savings under the Program. AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. If in the future you no longer want to receive these materials, please call 1-800-236-9933.

Please visit www.azprivacynotice.com to review our Privacy Notice.

*Required fields

STEP 1 OF 2: Get Started

 
I am commercially insured I am uninsured or use Medicare/Medicaid
 
Myself Someone I care for
 
 Asthma
 COPD, Emphysema, or Chronic Bronchitis
 None of the above
 
 Yes
 No

STEP 2 OF 2: Enter Your Details

In order to participate in the savings program, please enter your details below.

 
 
 
Male Female
 
 
 
 
 
 
 
 
 

By registering today, you will receive information about SYMBICORT, and may receive information about other respiratory medicines and services related to your condition.

You must be at least 18 years of age.

 Yes, I would also like to receive information in the future about all AstraZeneca products, programs, and services that may be of interest to me.
 

ELIGIBILITY

Offer good for eligible patients purchasing a 30-day fill (1 inhaler) of SYMBICORT® (budesonide/formoterol fumarate dihydrate). Eligible commercially insured patients will receive 100% off their out-of-pocket cost for each 30-day supply (one inhaler). If you pay cash for your prescription, you will receive up to $100 in savings on your out-of-pocket costs for each prescription. Offer good for 12 uses; each inhaler counts as 1 use. Offer not valid for prescriptions purchased under Medicaid, Medicare, or similar state or federally sponsored programs. Offer not valid for patients enrolled in a state or federally funded prescription insurance program even if patient elects to be processed as an uninsured patient. Offer valid for retail prescriptions, residents of the United States and Puerto Rico, and patients over 12 years of age only. Patient is responsible for any applicable taxes. Offer is not transferable, is not insurance, is limited to one per person, and may not 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. Offer may be changed or discontinued at any time without notice. Offer not conditioned on any past, present, or future purchase. More details on mySymbicort.com. Please call 1-844-798-3617 with questions and for full eligibility details. Card expires on 12/31/2017.

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 $0 on a 30-day supply. For Insured/Not Covered Patients: Submit this 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 eligible patient’s out-of-pocket costs to $0 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 (eg, 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

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 different 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 medical 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 may cause serious side effects, including:

  • Using too much of a LABA medicine may cause chest pain, increase in blood pressure, fast and irregular heartbeat, headache, tremor, or nervousness
  • Fungal infection in your mouth or throat (thrush). Rinse your mouth with water after using SYMBICORT to help reduce your chance of getting thrush
  • Pneumonia and other lower respiratory tract infections. People with COPD may have a higher chance of pneumonia and other lung infections. 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
  • Immune system effects and a higher chance for infections. 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
  • Increased wheezing right after taking SYMBICORT. Always have a rescue inhaler with you to treat sudden wheezing
  • Serious allergic reactions including rash, hives, swelling of the face, mouth and tongue, and breathing problems
  • 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
  • Eye problems including glaucoma and cataracts. You should have regular eye exams 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 and swelling of the sinuses
  • Decreases in blood potassium levels (hypokalemia)
  • Increases in blood sugar levels (hyperglycemia)

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

The most common side effects in patients with COPD include throat irritation, inflammation of the nasal passages and throat, thrush in the mouth and throat, bronchitis, sinusitis, and upper respiratory tract infection.

Approved Uses for SYMBICORT

SYMBICORT is a medicine for the treatment of asthma for people 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 80/4.5 is for the treatment of asthma for children 6 to less than 12 years. SYMBICORT 80/4.5 and 160/4.5 are for the treatment of asthma for people 12 years and older. SYMBICORT is not a treatment for sudden asthma symptoms.

SYMBICORT 160/4.5 is for adults with COPD, including chronic bronchitis and emphysema.

You should only take 2 inhalations of SYMBICORT twice a day.

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

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.