Use this form to enroll into Access 360 support and AstraZeneca's affordability programs. You may need to provide additional information depending on the type of support requested.

To get started, complete this enrollment form, download the populated form, print, sign and then fax to 1-844-FAX-A360 (1-844-329-2360).

Health Care Providers can enroll their patients online:

Enter Access 360 Portal

Choose an AstraZeneca Medicine:

Select Support:

Check all boxes that apply:

Comments:

COMPLETE SECTION 1

COMPLETE SECTIONS 1, 2 & 3

COMPLETE SECTIONS 1, 2 & 3

COMPLETE SECTIONS 1, 2 & 3

COMPLETE SECTIONS 1, 2, 3 & 4

COMPLETE SECTIONS 1, 2, 3 & 5

COMPLETE SECTIONS 1, 2, 3 & 4

COMPLETE SECTION 3

SECTION 1:

Patient Authorization

Access 360 Patient Authorization:

Access 360 is an optional program provided by AstraZeneca for patients, their caregivers, family, and providers. Access 360 can help you understand your coverage and financial obligation for AstraZeneca medicines and provide you with resources to help with treatment and payment for treatment.

By typing my name below, I authorize my health care providers and staff, my health plan, and my pharmacies to use and share Protected Health Information (my "Information") with AstraZeneca (including Access 360) and its affiliates, as well as its contractors ("AstraZeneca"). My Information includes my prescription-related health records, Information about my health care plan benefits, and any other Information bearing on my health. My Information may be used to verify, investigate, and assist with coordination of coverage for AstraZeneca products; track my prescription as requested by my physician; contact me about patient assistance programs; and perform internal analysis at AstraZeneca to better meet patient needs. I understand that federal privacy laws may not protect my Information once it is disclosed; however, AstraZeneca agrees to protect my Information by using and disclosing it only for purposes specified. I understand that I can refuse to sign this Authorization and that this will not affect my treatment or payment for treatment, insurance coverage, or eligibility for benefits. However, if I do not sign this Authorization, I will not be able to receive Access 360 support. I understand that I may cancel this Authorization at any time by mailing a letter requesting such cancellation to One MedImmune Way, Gaithersburg, MD 20878. I understand that any such cancellation will not apply to any Information already used or disclosed based on this Authorization prior to their receipt of the cancellation.

Patients are entitled to a signed copy. This authorization expires two (2) years from the date signed below, unless a shorter period is required by state law.

Patient Information

Physician Information

Please print form and sign on the signature line. Electronic or stamped signature will not be accepted.

*Signature of Patient/Legally Authorized Representative

*This authorization expires two (2) years from the date I sign this form unless a shorter period is required by state law.


Optional Enrollment:

By completing this registration, I understand that I may also receive ongoing information and support related to my condition including treatment information. This may include AstraZeneca or a third party working on AstraZeneca’s behalf contacting me by telephone regarding AstraZeneca support programs that may be of interest to me.

Information provided by AstraZeneca does not take the place of talking to your healthcare provider about your treatment or condition. AstraZeneca or third parties working on its behalf will not sell or rent your personal information. If in the future, you no longer want to receive these materials or calls, or to report a medication side effect, please call 1-800-236-9933. Please visit www.azprivacynotice.com to review our Privacy Notice.

Cradle With Care: Optional Enrollment

By completing this registration, I understand that I may also receive ongoing information and support related to my child's condition, including treatment information. Information sent by AZ does not take the place of talking to your healthcare provider about your treatment or condition. AZ, or third parties working on its behalf, will not sell or rent your personal information. If in the future you no longer want to receive these materials, or to report a medication side effect, please call 1-800-236-9933. Please visit www.azprivacynotice.com to review our Privacy Notice.

*Signature of Patient/Legally Authorized Representative

*This authorization expires two (2) years from the date I sign this form unless a shorter period is required by state law.

SECTION 2:

Patient Information/Insurance Information

Patient Information


Insurance Information

Primary Insurance
Secondary Insurance
Pharmacy Benefit

Income Information (Optional)

*All patients are automatically pre-screened for eligibility for the AstraZeneca AZ&Me free drug program if the information in this section is completed.

Number of people in household
(Include yourself, your spouse, and your dependents)

What is your total combined household income before taxes?
(Include yourself, your spouse, and your dependents)

   OR   

SECTION 3:

Provider Information

SECTION 4:

Prescription Information

Prescription Information

Has prescription already been submitted to pharmacy?

If Yes, please indicate where

Deliver medicine to

Ancillary supplies and kits as needed for administration

Sign and Date

I authorize AstraZeneca’s Access 360 program to convey the attached prescription on my behalf to the pharmacy chosen above and to receive information on the status and related matters. By signing above, I certify that the medicine prescribed on this form is medically necessary based on my independent medical judgment, and I have received the necessary authorization to release the information included on this form and other protected health information (as defined by HIPAA) to Access 360, the dispensing pharmacy or other contractors for the purpose of seeking reimbursement, assisting in initiating or continuing therapy. Each practitioner is solely responsible for ensuring the accuracy of the information submitted.


Dispense:

Administer 10 mg/kg as an intravenous infusion over 60 minutes every 2 weeks

Refill: times.

Specialty Pharmacy Provider (SPP):

*If you have questions about in-network SPP(s) for your patient, contact Access 360 at 1-844-275-2360.


250-mg tablet

80-mg tablet

Dose adjustment:
40-mg tablet

Specialty Pharmacy Provider (SPP):

*If you have questions about in-network SPP(s) for your patient, contact Access 360 at 1-844-275-2360.


150-mg tablet

Dose adjustment:
100-mg tablet

50-mg capsules

Dose adjustment

To avoid substitution errors and overdose, [do not substitute Lynparza tablets with Lynparza capsules] on a milligram-to-milligram basis due to differences in the dosing and bioavailability of each formulation.

Specialty Pharmacy Provider (SPP):

*Capsules will only be available through 2 SPPs. If you have questions about in-network SPP(s) for your patient, contact Access 360 at 1-844-275-2360.



Anticipated date of treatment:

I authorize AstraZeneca's Access 360 program to convey the attached prescription on my behalf to the pharmacy chosen above and to receive information on the status and related matters. By signing above, I certify that the medicine prescribed on this form is medically necessary based on my independent medical judgment, and I have received the necessary authorization to release the information included on this form and other protected health information (as defined by HIPAA) to Access 360, the dispensing pharmacy or other contractors for the purpose of seeking reimbursement, assisting in initiating or continuing therapy. Each practitioner is solely responsible for ensuring the accuracy of the information submitted.

I verify that the information provided on this form is accurate. I understand that the patient must have an FDA-approved diagnosis to be eligible for free limited supply. Reimbursement for the cost of the product administered to the above patient on the date(s) indicated has not been sought and will not be sought from any source. Additionally, I understand that AstraZeneca reserves the right to conduct periodic audits of the records, excluding patient-identifiable data (unless patient authorization is on file with AstraZeneca Access 360), of all entities receiving free limited supply. I understand that AstraZeneca reserves the right to modify or revoke this program at any time without notice. My signature confirms that this product was provided free of charge to this patient.

SECTION 5:

AstraZeneca Patient Savings Program

For commercially insured patients, the AstraZeneca Patient Savings Program is available for the following medications:
IMFINZI (durvalumab) FASLODEX® (fulvestrant) IRESSA® (gefitinib) TAGRISSO® (osimertinib) LYNPARZA® (olaparib)

The AstraZeneca Patient Savings Program is available for commercially insured or uninsured SYNAGIS® (palivizumab) patients.

Use this form to enroll patients to the IRESSA® (gefitinib) TAGRISSO® (osimertinib) or LYNPARZA® (olaparib) AstraZeneca Patient Savings Program. Alternatively, you can enroll and view patients online via the Patient Savings Program enrollment portal at www.AstraZenecaSpecialtySavings.com

IMPORTANT: This form cannot be used to enroll patients into the IMFINZI (durvalumab) or FASLODEX® (fulvestrant) Patient Savings Program; patients must be enrolled into those programs via the enrollment portal.

When using the enrollment portal, at the completion of the enrollment process you will receive patient-specific account information available for immediate use. In addition, you can log in at any time to review program utilization and remaining balance information. This information will not be available if you enroll the patient using this form.

Answer the following questions to certify compliance with the terms and conditions of the program:

1. I certify that I have received an appropriate authorization to proceed with the enrollment of this patient:


2. Is the patient on commercial (also known as private) Insurance?


3. Are the patient’s prescriptions paid for in part or in full under any federally funded programs?

3. Based on your inquiry of patient insurance status, are the patient's prescriptions paid for in part or in full under any federally funded programs, including but not limited to Medicare Part B, Medicaid, Medigap, VA, DoD or TRICARE?


4. Is the patient a current resident of one of the 50 United States or Puerto Rico?

5. I have any appropriate authorization to share patient information disclosed during this enrollment, including name, Email address, mailing address, and phone number, with AstraZeneca, the sponsor of the card, as well as parties working on behalf of AstraZeneca. The information shared will include the date that the patient filled the prescription, specifics about the medication dispensed by the pharmacist, and out-of-pocket costs:


6. Required information if not already indicated on this enrollment form:

7. Required clinical information:

8. For this program, the default mechanism of payment is via Coordination of Benefits (COB). This means the pharmacy submits the program information (RxBIN, PCN, Group ID, Member ID) on the secondary claim line of the insurance form. This can be done for SYNAGIS covered under the Medical or Pharmacy benefit. If the provider is unable to submit claims to the program for this patient using the COB mechanism, please indicate below and a virtual debit card will be generated for the patient.