Sworn declaration of tailored affordability support 

CC- 7180/Febrero 2024

You have been accepted for enrollment in the “AstraZeneca Tailored Affordability Support” access program (The Program), since your doctor proceeded with the prescription of an AstraZeneca product included in this program, and the respective validation of compliance for the inclusion criteria.


The Program was created to support the needs of patients, through a collaborative model in which patients and AstraZeneca share the cost of AstraZeneca’s included therapies (Calquence®, Fasenra®, Imfinzi®, Lynparza® and Tagrisso® ).


You would benefit from a 1 + 1 treatment scheme for your AstraZeneca therapy (1 pack purchased + 1 free). For this treatment scheme, you must cover the cost of 1 month of treatment to receive an equivalent month of the product free of charge .


The Program is part of AstraZeneca’s “Celebrate Life” services, so you must also agree to the “Celebrate Life” Terms and Conditions, as well as the informed consent for this support program.


This document will provide you with additional information about the Access Program, it is important to clarify that it does NOT replace the indications of your doctor or medical team in charge.
If you have questions about your treatment, you should discuss it with your treating doctor.


HOW DOES THE ACCESS PROGRAM WORK?


• Your doctor has informed you about the Access Program. The information obtained from you when entering the Access Program will be stored in accordance with the terms and conditions that you accepted as a previous step in “Celebrate Life”.
• The Access program could end if a non-response to your treatment is documented (no further clinical benefit assessed by your physician), you present intolerance or toxicity to the treatment, or if your doctor indicates its suspension.
• You and your treating physician will be responsible for the product administration process prescribed by your physician.

• Administration costs or costs associated with therapy must be covered by you as the patient, will not be covered by AstraZeneca, and must be coordinated with your treating physician.
• You must inform the Access Program immediately when your doctor considers discontinuing treatment, in order to end participation in the program.


WHAT WILL YOU RECEIVE AS PART OF THE ACCESS PROGRAM?


• You will receive a fixed support scheme, where you will proceed with the purchase of one (1) month of AstraZeneca treatment prescribed by your doctor and together with the purchase you will receive an additional month of your treatment free of charge.
• The supply of the product approved for the program will be delivered to you for use in line with the approved product insert in your country and under the direction of your doctor.
• The supply will be coordinated with the person in charge of the AstraZeneca patient program, your doctor and the pharmacy or clinic authorized for purchase and delivery.


HOW LONG WILL YOU RECEIVE TREATMENT IN THE ACCESS PROGRAM?


• You will receive treatment with the AstraZeneca product approved for the program, from the moment you finish the enrollment process in the Program, and in which you subsequently make the coordination for purchase and delivery.
• You will have the benefit of 1+1 (1 month of purchase + 1 month free of cost) for the period that your doctor considers should continue the treatment. For the continuity of the benefit, the purchase of your treatment is mandatory in order to receive the product free of charge.
• As a patient, you can decide to withdraw from the program at the time you or your doctor consider it appropriate.
• If for a continuous period of 4 months, you do not proceed with the planned purchase of your treatment, you will be notified and inactivated from the access program .
• The provision of the 1+1 benefit of the treatment of the AstraZeneca Program could end if the non-response to your treatment, intolerance or toxicity to the treatment is documented, or if your doctor indicates its suspension.

TREATMENT COVERAGE STATEMENT


By reading this document and accepting it, you declare that you have insufficient coverage to be able to purchase the AstraZeneca treatment prescribed by your doctor, or that your private insurance coverage (if you have it) does not fully covers the cost of your treatment.


COLLECTION AND REPORTING OF SECURITY INFORMATION


If you as a patient experience an Adverse Event (AE), a dose reduction or interruption due to an AE, a special situation or a product quality complaint, AstraZeneca Patient Safety should be reported via:
• online reporting portal https://www.contactazmedical.astrazeneca.com
• by contacting a local AstraZeneca representative to proceed with the report

TAILORED AFFORDABILITY SUPPORT – BY ASTRAZENECA