Introducing SYMBICORT Savings Program*

Introducing SYMBICORT Savings Program*

FOR ELIGIBLE

COMMERCIALLY

INSURED PATIENTS

FREE.

EVERY FILL.EVERY MONTH.*

*Subject to eligibility rules; restrictions apply.

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

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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 6 years of age subject to label indication. 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/covered patients with no restrictions (step-edit, prior authorization or NDC block) and 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 covered 30, 60, or 90-day supply (1-3 inhalers), respectively. If you pay cash for your prescription, are insured and your insurance does not cover or has a managed care restriction on your prescription (step-edit, prior authorization or NDC block), you will receive up to $100 in savings on your 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 12/31/18. If you have any questions regarding this offer, please call 1-844-798-3617.1-844-798-3617.

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.

Program managed by ConnectiveRx, on behalf of AstraZeneca.

*Subject to eligibility rules; restrictions apply.