Please fill out the short form below to activate your AZhelps Savings Card. After submitting, you can start using your card right away.
By completing this registration, you are confirming that you are at least 18 years old, are a resident of the US, and would like to receive information in the future about DALIRESP and related health information, including support related to your condition and treatment information.
AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. Certain information pertaining to your participation will be shared with AstraZeneca, the sponsor of the Program. The information shared will include the date that you filled the prescription, the quantity of medication dispensed by your pharmacist, and your savings under the Program. AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. If in the future you no longer want to receive these materials, please call 1-800-236-9933.
Please visit www.azprivacynotice.com to review our Privacy Notice.
All fields required unless marked optional.
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 who are over 18 years of age. This offer is not valid for mail order.
Eligible commercially insured patients with a valid prescription for DALIRESP® (roflumilast) tablets who present this savings card at participating pharmacies may pay as little as [$25] per 30-day supply 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 30-day supply.] 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 30-day supply counts as 1 use. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Card must be used on or before [12/31/18]. If you have any questions regarding this offer, please call [1-866-459-2015].
Program managed by ConnectiveRx, on behalf of AstraZeneca.