Introducing SYMBICORT $0 Savings Guarantee Program*

Introducing SYMBICORT $0 Savings Guarantee Program*

The only ICS/LABA with a $0 offer

Eligible commercially insured patients pay no more than $0 for each prescription—including those with restrictions on prescription benefit coverage*

SYMBICORT—Reliable preferred coverage for more than 139 million lives nationwide‡1

The SYMBICORT $0 Savings Guarantee Program is for all eligible commercially insured patients, including

  • NDC Block
  • In EMR System as
  • Prior Authorization
  • High Deductibles
  • Tier 3
  • Tier 2

SYMBICORT is NOT a rescue medication and does NOT replace fast-acting inhalers to treat acute symptoms

“Preferred” means Tier 1, Tier 2, or Tier 3 when Tier 3 is the lowest branded tier.

Based on September 30, 2016 Fingertip Formulary data for the total number of Medicare Part D and commercially insured members of plans nationwide with Preferred coverage for SYMBICORT in the US, which includes the 50 states, District of Columbia, and Puerto Rico.

SYMBICORT Savings Card Coupon

*Subject to complete eligibility rules below; restrictions apply.

“Preferred” means Tier 1, Tier 2, or Tier 3 when Tier 3 is the lowest branded tier.

Based on September 30, 2016 Fingertip Formulary data for the total number of Medicare Part D and commercially insured members of plans nationwide with Preferred coverage for SYMBICORT in the US, which includes the 50 states, District of Columbia, and Puerto Rico.

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Eligibility

Patients may be eligible for this offer if they are insured by commercial insurance and their insurance does not cover the full cost of their prescription, or they are not insured and are responsible for the cost of their 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.

Patients who are enrolled in a state or federally funded prescription insurance program may not use this savings card even if they 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.

If you use a mail-order pharmacy, please contact your pharmacy provider to confirm if this offer will be accepted.

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 receive 100% off their out-of-pocket costs for each 30, 60, or 90-day supply (1-3 inhalers), respectively. Patients who pay cash for your prescription will receive up to $100 in savings on their out-of-pocket costs for each prescription. This offer is good for 12 uses and each inhaler counts as 1 use. Patient is responsible for applicable taxes, if any. Card expires on 12/31/17. For questions regarding this offer, please call 1-866-421-2848.1-866-421-2848.

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.

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

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

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

*Subject to eligibility rules; restrictions apply.