COMMERCIAL INSURANCE

START, SAVE, AND STAY ON BRILINTA

BRILINTA® (ticagrelor) Savings Card

ELIGIBLE PATIENTS PAY AS LOW AS $5*

With the BRILINTA Savings Card, your monthly cost for BRILINTA could be as low as $5.* For most people, that’s less than the cost of the generic form of Plavix.

*Commercially insured patients. Eligible patients will pay as low as $5 for each 30-day supply for as long as their doctor prescribes BRILINTA, subject to a maximum savings of $200 per 30-day supply. Subject to eligibility rules below; restrictions apply.

Commercially insured patients who were not in a Federally funded program were used to support this claim. Source: ConnectiveRx data from January 2017-March 2018 and Fingertip Formulary® data accessed on April 16, 2018.

Cost comparisons do not imply comparable efficacy, safety, or FDA-approved indications.

WAYS TO GET THE BRILINTA SAVINGS CARD

APPLE WALLET OR GOOGLE PAY

Add the savings card to your Apple® Wallet or Google Pay™. After the card is added, you can access it at any time.

ACTIVATE CARD

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Google Pay is a trademark of Google LLC.

TEXT MESSAGE

Enter your mobile phone number below to receive your savings card through a text message.

Message and data rates may apply. Average 5 messages per month. Text STOP to opt out. Text HELP for help. Privacy Policy. Terms and Conditions.

DOWNLOAD THE CARD

DOWNLOAD THE CARD

Download and print the savings card now.

GET THE CARD ON YOUR PHONE

Text “SAVE6” to 99789 to get a coupon code sent to your phone.

OR

Enter your mobile phone number below to receive your savings card through a text message.

Message and data rates may apply. Average 5 messages per month. Text STOP to opt out. Text HELP for help. Privacy Policy. Terms and Conditions.

Message and data rates apply. Average 5 messages per month. Text STOP to opt out. Text HELP for help. Privacy Policy. Terms and Conditions.

You can also add the card to your Apple® Wallet or Google Pay™ by visiting our site on your mobile device.

Apple is a registered trademark of Apple Inc.

Google Pay is a trademark of Google LLC.

TO USE THE CARD, BRING IT TO THE PHARMACY ALONG WITH YOUR PRESCRIPTION

ARE YOU ELIGIBLE TO USE THE BRILINTA SAVINGS CARD?

  • You have commercial insurance
  • You are 18 years of age or older
  • You live in the United States or its territories

Subject to eligibility rules below; restrictions apply.

DO YOU FILL YOUR PRESCRIPTION BY MAIL?

MAIL-IN REBATE

You may pay as low as $5§ for each 30-day prescription. Here’s how:

  1. Fill out a Patient Rebate Form online. You may also call 1-888-462-3705 to request one, or print one.
  2. Attach the original mail-order receipt and return it to the address listed on the form. Keep a copy of your receipts for your records.
  3. Receive your check in about 2 to 3 weeks.

§Subject to eligibility rules below; restrictions apply. Patient must remain eligible for the duration of the offer.

QUESTIONS TO ASK YOUR DOCTOR

Savings Card Terms and Conditions

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 18 years of age.

TERMS OF USE: Eligible commercially insured patients with a valid prescription for BRILINTA® (ticagrelor) tablets who present this savings card at participating pharmacies will pay as low as $5 per 30-day supply. $200 maximum savings limit applies; patient’s out-of-pocket expense may vary. If you pay cash for your prescription, AstraZeneca will pay up to the first $100, and you will be responsible for any remaining balance, for each monthly prescription. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Nontransferable, 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 at the time of purchase. For additional details about this offer, please visit BRILINTA.com. If you have any questions regarding this offer, please call 1-800-422-5604.

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

Pharmacist Instructions for a Patient with an Eligible Third Party:

For Commercially Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 8. The patient is responsible for the first $5 and the card pays up to the next $200 per 30-day supply; patient’s out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.

Pharmacist Instructions for a Cash-Paying Patient: Submit this claim to Change Healthcare. A valid Other Coverage Code (eg, 1) is required. The card will cover up to $100 per 30-day supply. Reimbursement will be received from Change Healthcare. Patients enrolled in a state or federally funded prescription insurance program may not use this savings card.

Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the Help Desk 1-800-422-5604.

Eligibility for Mail-Order Rebate

Eligibility for Free Trial Offer for Commercially Insured Patients: 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. 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. This offer is not insurance and is restricted to residents of the United States and Puerto Rico and patients over 18 years of age. This offer is valid for retail prescriptions only.

Terms of use: Eligible commercially insured patients with a valid prescription for BRILINTA® (ticagrelor) tablets who present this offer at participating pharmacies will receive 100% off their co-pay for one 30-day prescription. Other restrictions may apply. Patient is responsible for applicable taxes, if any. If you have any questions regarding this offer, please call 1-800-422-5604. Nontransferable, 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 BRILINTA® at the time of purchase.

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

Eligibility for Free Trial Offer for Medicare or Medicaid Patients: This offer is good for eligible patients purchasing up to a 30-day supply (up to 60 tablets) of BRILINTA® (ticagrelor) tablets and may not be used for any other product. This offer is good for the purchase of BRILINTA® manufactured for AstraZeneca Pharmaceuticals LP and lawfully purchased from an authorized retailer or distributor in the United States or its territories. This offer may be used by eligible patients who participate in Medicaid, Medicare, or similar federal or state programs, or by patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees. This offer is not insurance and is not valid for mail order, or for patients under 18 years of age. Offer not valid where prohibited by law, taxed, or restricted. Offer is not transferable, is limited to one per person, and may not be combined with any other offer. Offer must be presented along with a valid prescription for BRILINTA® at the time of purchase.

Medicaid or Medicare Patients: You will receive one 30-day prescription free. If you have any questions regarding this offer, please call 1-800-422-5604. AstraZeneca reserves the right to change or discontinue this offer at any time without notice. No claim for payment can be made to ANY Third-Party Payer for product dispensed pursuant to this offer. Not valid if reproduced.

Pharmacist instructions for Commercially Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code (eg, 8). The patient is responsible for $0.00. Reimbursement will be received from Change Healthcare.

Pharmacist instructions for Medicare or Medicaid Patients: Submit this claim to Change Healthcare. The information printed below should be used when submitting for reimbursement. No claim for payment can be made to ANY Third-Party Payer for product dispensed pursuant to this offer. Not valid if reproduced.

For any questions regarding Change Healthcare online processing, please call the Help Desk 1-800-422-5604.

IMPORTANT SAFETY INFORMATION ABOUT BRILINTA® (ticagrelor), INCLUDING BOXED WARNINGS, FOR 60-MG AND 90-MG TABLETS Read More

BRILINTA is used to lower your chance of having another heart attack or dying from a heart attack or stroke, but BRILINTA (and similar drugs) can cause bleeding that can be serious and sometimes lead to death. Instances of serious bleeding, such as internal bleeding, may require blood transfusions or surgery. While you take BRILINTA, you may bruise and bleed more easily and be more likely to have nosebleeds. Bleeding will also take longer than usual to stop.

Approved Use

BRILINTA is a prescription medicine for people who have had a heart attack or severe chest pain that happened because their heart wasn’t getting enough oxygen.

IMPORTANT SAFETY INFORMATION ABOUT BRILINTA® (ticagrelor), INCLUDING BOXED WARNINGS, FOR 60-MG AND 90-MG TABLETS

BRILINTA is used to lower your chance of having another heart attack or dying from a heart attack or stroke, but BRILINTA (and similar drugs) can cause bleeding that can be serious and sometimes lead to death. Instances of serious bleeding, such as internal bleeding, may require blood transfusions or surgery. While you take BRILINTA, you may bruise and bleed more easily and be more likely to have nosebleeds. Bleeding will also take longer than usual to stop.

Call your doctor right away if you have any signs or symptoms of bleeding while taking BRILINTA, including: severe, uncontrollable bleeding; pink, red, or brown urine; vomit that is bloody or looks like coffee grounds; red or black stool; or if you cough up blood or blood clots.

Do not stop taking BRILINTA without talking to the doctor who prescribes it for you. People who are treated with a stent, and stop taking BRILINTA too soon, have a higher risk of getting a blood clot in the stent, having a heart attack, or dying. If you stop BRILINTA because of bleeding, or for other reasons, your risk of a heart attack or stroke may increase. Tell all your doctors and dentists that you are taking BRILINTA. To decrease your risk of bleeding, your doctor may instruct you to stop taking BRILINTA 5 days before you have surgery. Your doctor should tell you when to start taking BRILINTA again, as soon as possible after surgery.

Take BRILINTA and aspirin exactly as instructed by your doctor. You should not take a dose of aspirin higher than 100 mg daily because it can affect how well BRILINTA works. Tell your doctor if you take other medicines that contain aspirin. Do not take new medicines that contain aspirin.

Do not take BRILINTA if you have a history of bleeding in the brain, are bleeding now, or are allergic to ticagrelor or any of the ingredients in BRILINTA.

Slow heart rhythm has been reported with BRILINTA.

BRILINTA can cause serious side effects, including bleeding and shortness of breath. Call your doctor if you have new or unexpected shortness of breath or any side effect that bothers you or that does not go away. Your doctor can decide what treatment is needed.

Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. BRILINTA may affect the way other medicines work, and other medicines may affect how BRILINTA works. Tell your doctor if you are breastfeeding or plan to breastfeed. You should not breastfeed while being treated with BRILINTA.

APPROVED USE

BRILINTA is a prescription medicine for people who have had a heart attack or severe chest pain that happened because their heart wasn’t getting enough oxygen.

BRILINTA is used with aspirin to lower your chance of having another serious problem with your heart or blood vessels such as heart attack, stroke, or blood clots in your stent if you received one. These can be fatal.

Please read Medication Guide and Prescribing Information, including Boxed WARNINGS, for BRILINTA.

You may report side effects related to AstraZeneca products by clicking here.