You can download a blank application, print it out and then fill in your information by hand; or, you can fill in the application on your computer screen by selecting "Fill in Application & Print", clicking on the "Highlight Fields" button at the upper right of the document, and then typing in your information directly onto the form. Does not have a history of breast cancer 5. 3ch�mǧG(m�u�δ�i�0zg���6�.X���%?6LV�)��aO_�~�� You can then print the application form and sign it. Yes No (if yes) Is your patient at a high risk for fractures, such as a T-score of … The Provider Does the patient have a history of one of the following: Bilateral orchiectomy 2���9ˍht���j��oCP�%Y��P�t�������e}{`Z�� At AstraZeneca, we view the safety and wellbeing of our patients as the highest priority. Page 6 © 2020 Express Scripts. Find out how to download an application to avail the AstraZeneca savings program. Whether you want endobj You can download a blank application, print it out and then fill in your information by hand; or, you can fill in the application on your computer screen by selecting "Fill in Application & Print", clicking on the "Highlight Fields" button at the upper right of the document, and then typing in your information directly onto the form. The Cart is a temporary place to store a list of your items and reflects each item's most recent price. <> (Arimidex) Coverage for $0 copayment will be provided when: 1. %PDF-1.5 the information and support you need to take control of your health. <>/XObject<>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 16 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Shopping Cart Learn more specialist pharmacists to help you understand your therapy, we’re here to help.Your prescription may be processed by any pharmacy within our family of Express Scripts mail-order pharmacies.We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex.URAC Accredited Pharmacy Benefit Management, Expires 11/01/2022URAC Accredited Mail Service Pharmacy, Expires 11/01/2020 Our Program continues to monitor the COVID-19 pandemic and its related impacts and deploy appropriate actions to support patients. This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

<>>> Either way, you will have to mail the form to us or have it faxed from your doctor's office after you've printed it out.Please read the information below carefully and choose the application for the medicine that you are requesting.For assistance with a product not mentioned below, please use the General Application.Find out if you qualify for one of the AZ&Me Prescription Savings Programs Please see full Prescribing Information, including Boxed WARNING(S) for BEVESPI AEROSPHERE, BRILINTA, BYDUREON, BYDUREON BCise, BYETTA, CALQUENCE, DALIRESP, FARXIGA, FASENRA, FASLODEX, IMFINZI, IRESSA, KOMBIGLYZE XR, KOSELUGO, LOKELMA, LUMOXITI, LYNPARZA, MOVANTIK, ONGLYZA, PULMICORT FLEXHALER, QTERN, SYMBICORT, SYMLIN, TAGRISSO and XIGDUO XR are registered trademarks and AZ&Me is a trademark of the AstraZeneca group of companies.

independent manager of pharmacy benefits in the United States and one of the Blue Cross Blue Shield of Michigan Blue Care Network … Member is currently post-menopausal Androderm See testosterone . We will keep you apprised of all new actions deployed to ensure you have uninterrupted access to your medication.This site is intended for US consumers and Health Care Professionals only.You can choose to fill out your application in one of two ways. Either way, you will have to mail the form to us or have it faxed from your doctor's office after you've printed it out.Please read the information below carefully and choose the application for the medicine that you are requesting.For assistance with a product not mentioned below, please use the General Application.Find out if you qualify for one of the AZ&Me Prescription Savings Programs Please see full Prescribing Information, including Boxed WARNING(S) for BEVESPI AEROSPHERE, BRILINTA, BYDUREON, BYDUREON BCise, BYETTA, CALQUENCE, DALIRESP, FARXIGA, FASENRA, FASLODEX, IMFINZI, IRESSA, KOMBIGLYZE XR, KOSELUGO, LOKELMA, LUMOXITI, LYNPARZA, MOVANTIK, ONGLYZA, PULMICORT FLEXHALER, QTERN, SYMBICORT, SYMLIN, TAGRISSO and XIGDUO XR are registered trademarks and AZ&Me is a trademark of the AstraZeneca group of companies. Our Program continues to monitor the COVID-19 pandemic and its related impacts and … The price and availability of items at Amazon.com are subject to change. … 4 0 obj 2xNC�$4L`������O��9X� [ov�|�1�K�zgl��{����sim�+�����3�؝5���L?

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If you are impacted by Hurricane Laura or fires on the west coast, log in to find a network pharmacy nearby. At AstraZeneca, we view the safety and wellbeing of our patients as the highest priority. 5���yL0��z��|�T�F�+�G��o_���.���>�D���Y��X1����3����Tl\�$U��(}kMe ��)��~��@����tȌ�a�r�Z*P�,o,U����R-cՆi� We’re happy to have the opportunity to support your prescription drug coverage needs. An open pharmacy can get your prescription information and fill your medication. That’s why we’re available 24/7 to give you This section of the site contains resources and tools you can use to simplify your coverage and get the most value from your plan. �"Ms��H�`�&K�Ducud�4C��c�0�=D�V|�,Q�L�Bx��_e]��-/��]8��W��,V_@���,���)6���2���}A��� F�=��#���A�Vj,�uA�O�u���z2�E�1ɑ5��� �_.�$V��n'QX�����l����s9����$9}�y���_�H2'����BK҂��u��ku��Wi]�� t��,��2+��%�u�|�,hZ�����T������,-XR2��Q�o�1�e���!��5����o��x�fe�$D��)��C�0���~�������:�����8Unq�@��e����XE�����8�&� u� The price and availability of items at Amazon.com are subject to change.