With the BRILINTA Savings Card, commercially insured patients could pay as low as $5* for a 30-day supply of BRILINTA each and every time they refill.
*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.
Cost comparisons do not imply comparable efficacy, safety, or FDA-approved indications.
Check the box that describes how you want to receive the Savings Card. When you receive your Savings Card, you will also receive support and treatment tips from BRILINTA to your email.
Check the box that describes how you want to receive the Savings Card. When you receive your Savings Card, you will also receive support and treatment tips from BRILINTA to your email.
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†Subject to eligibility rules below; restrictions apply.
You may pay as low as $5‡ for each 30-day prescription. Here’s how:
‡Subject to eligibility rules below; restrictions apply. Patient must remain eligible for the duration of the offer.
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.
TERMS OF USE: Eligible commercially insured/covered patients with no restrictions (step-edit, prior authorization, or NDC block) and 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. A $200 maximum savings limit applies; patient’s out-of-pocket expense may vary. If you are insured and your insurance does not cover or has a managed-care restriction on your prescription (step-edit, prior authorization, or NDC block), you will pay as low as $5 per 30-day supply. If you pay cash for your prescription, AstraZeneca will pay up to the first $100 per month, 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 www.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 Payer:
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. This will reduce the eligible patient’s out-of-pocket costs to as low as $5 for each 30-day supply, subject to a maximum savings limit of $200 for the program; patient’s out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.
Pharmacist Instructions for Insured/Not Covered Patients: Submit the claim to the primary Third-Party Payer first; if the primary claim submission shows a managed-care restriction (step-edit, prior authorization, or NDC block), continue the claim adjudication process and submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 3. This will reduce eligible patient’s out-of-pocket costs to as low as $5 for each 30-day supply, subject to a maximum savings limit for the program; 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 may cover up to a maximum of $100 per each 30-day supply. Reimbursement will be received from Change Healthcare. For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-422-5604.
Program managed by ConnectiveRx on behalf of AstraZeneca.
BRILINTA is used to lower your chance of having, 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. In most cases, 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, shortness of breath, and irregular breathing. Call your doctor if you have new or unexpected shortness of breath or irregular breathing, or any side effect that bothers you or 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.
Please read Medication Guide and Prescribing Information, including Boxed WARNINGS, for BRILINTA.
You may report side effects related to AstraZeneca products .
