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.
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 12/31/2016. If you have any questions regarding this offer, please call 1-866-421-2848.
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.
If your commercial insurance plan does not cover SYMBICORT, use of this offer permits your health care 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.
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.