Know Your Patient's Copay for BRILINTA

Complete the form below to learn your patient's copay for BRILINTA and how they may be able to save on their medication.

*indicates a required field

*What insurance plan does your patient use to pay for their medication?

Patient Information

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

Prescription Insurance Information

*Prescription Insurance Name
*Rx Group  ?
RX PCN  ?

*Member ID (Card ID)  ?
*RX BIN Number  ?
*Insurance Phone Number

Policyholder Information

*Policyholder First Name:
*Policyholder Last Name:
*Policyholder Zip Code:
*Patient’s 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 at 1-888-51-BRILINTA (1-888-512-7454) 7:00am - 9:00pm ET, seven days per week to help healthcare professionals determine BRILINTA prescription benefits and answer any coverage questions.

Consent Agreement

By submitting this form, I agree that as a licensed practicing healthcare provider, I am requesting that Access My BRILINTA provide reimbursement services for my patient, for whom I have prescribed BRILINTA as indicated. I certify that this therapy is medically necessary and that the information I have provided is accurate to the best of my knowledge. I also represent that I have received appropriate HIPAA authorization from the patient to disclose this information to Triplefin LLC, an agency acting on behalf of AstraZeneca Pharmaceuticals, for the purpose of assessing whether the patient qualifies for reimbursement assistance. 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. If you would like to obtain supplemental authorization from your patient, click here.