What’s Your Copay for BRILINTA?

Complete the form below to learn your copay† for BRILINTA and how you may be able to save on your medication.

*indicates a required field

*What insurance plan do you use to pay for your medication?

Make sure you have the insurance card you use at your pharmacy available. If you need help locating this important information from your health insurance card please call 1-888-51-BRILINTA (1-888-512-7454) between 7 am - 9 pm ET, seven days per week to speak with a Customer Service Representative.

Patient Information

  
*Patient First Name
*Patient Last Name
*Patient Gender
*Patient Date of Birth



Policyholder Information

*Policyholder First Name:
*Policyholder Last Name:
*Policyholder Zip Code:
*Patient Relationship to Policyholder

Please review the information you entered for accuracy before submitting. If you need help, Access My BRILINTA Customer Service Representatives are available by telephone 1-888-51-BRILINTA (1-888-512-7454) 7 am - 9 pm ET, seven days per week to help you determine BRILINTA prescription benefits and answer any coverage questions.

Consent Agreement

By submitting this form, I am disclosing information to Triplefin LLC, an agency acting on behalf of AstraZeneca Pharmaceuticals, for the purpose of determining my prescription insurance coverage for BRILINTA. This information will not be used for any other reason other than to provide information about BRILINTA. Personal Health Information will not be rented or sold and will be stored in an encrypted database. I acknowledge that Triplefin LLC may use this information to contact my healthcare provider or insurance provider for information relevant to this request.