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Register for savings offers & support

For your FREE Trial Offer,* a Savings Card,* and to take advantage of BRILINTA Patient Support Service, please call 1-888-512-7454 or complete the information below.

BRILINTA Patient Support Service, which is available 365 days a year, specializes in helping people who have had a recent heart attack or severe chest pain, also known as Acute Coronary Syndrome (ACS), and now take BRILINTA. It can help in many ways, including:

  • Insurance coverage questions
  • Providing tips to help you remember to take your medication
  • Setting up refill reminders
  • Understanding your condition
  • Ongoing patient support e-mail communications

*Subject to eligibility rules; restrictions apply.

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 number of pills 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 1-888-512-7454.

Please visit www.azprivacynotice.com to review our Privacy Notice.

*Field is required

Brilinta Registration

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 Patient
 Caregiver
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Birth Date *

By providing your date of birth, you verify that you are at least 18 years of age.

 Send me support materials to my postal address.

Month and year of hospitalization for heart attack or severe chest pain.

Please select valid month and year
Please select valid state
*
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 No
 
 Yes, I would like to receive (coaching) calls
 

I prefer to receive calls:

 
 Yes
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413836669268

 
 E-mail
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 Yes, I would like to receive information in the future about BRILINTA and related health information.
 
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*Eligibility for Combined Free Trial Offer and Savings Card Offer for Commercially Insured and Cash-Paying Patients:

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 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. Cash-paying patients will receive one 30-day prescription free. On each of their next 11 uses (and each 30-day supply counts as 1 use), eligible commercially insured patients will pay $18 per 30-day supply, subject to a maximum savings of $75 per 30-day supply. Cash-paying patients will receive up to $75 in savings on out-of-pocket costs per 30-day supply. This offer is good for a 30-day supply, 60-day supply, or 90-day supply. Other restrictions may apply. Patient is responsible for applicable taxes, if any. If you have any questions regarding this offer, please call 1-888-512-7454.

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.

Program managed by PSKW, LLC, on behalf of AstraZeneca.

Eligibility for Free Trial Offer for Medicare/Medicaid Patients:

Eligibility for FREE Trial Offer: 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 1-888-512-7454. 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.

Program managed by PSKW, LLC, on behalf of AstraZeneca.

Eligibility for Mail-Order Rebate for Commercially Insured and Cash-Paying Patients:

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 rebate form even if you elect to be processed as an uninsured (cash-paying) patient. This offer is not insurance and is restricted to residents of the United States and Puerto Rico and patients over 18 years of age.

TERMS OF USE: This offer is good for eligible patients purchasing a 90-day supply (up to 180 tablets) of BRILINTA® (ticagrelor) tablets through a mail-order pharmacy and may not be used for any other product. If you have commercial insurance for your prescriptions and your co-pay is more than $54 for a 90-day supply, you will pay the first $54 and receive up to $225 in savings from AstraZeneca. If you pay cash for your prescriptions, you will receive up to $225 in savings from AstraZeneca for a 90-day supply. This offer is good for a 90-day supply (up to 4 fills). If you have any questions regarding this offer, please call 1-888-512-7454.

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 REBATE FORM, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

Program managed by PSKW, LLC, on behalf of AstraZeneca.

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