copayportal.paysign.com
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Submitted URL: http://autodandomain-vendordiamondstorefig-lab.tagrissosavings.com/
Effective URL: https://copayportal.paysign.com/enrollment/5727846689/index.html
Submission: On November 16 via api from DK — Scanned from DK
Effective URL: https://copayportal.paysign.com/enrollment/5727846689/index.html
Submission: On November 16 via api from DK — Scanned from DK
Form analysis 3 forms found in the DOM
<form><input type="hidden" name="enrollment_id"><input type="hidden" name="program" value="PYS"><input type="hidden" name="patient_id">
<div class="form mt-2">
<div class="row">
<div class="col-md-12">
<div class="form-title">1. Basic Information</div>
<p class="description">Patient Basic Information.<br>
<font color="red">* Required field.</font>
</p>
</div>
</div>
<div class="card no-overflow">
<div class="container">
<div class="row mb-2">
<div class="col col-6"><label class="info-label">First Name <span class="marked-required">*</span></label><input type="text" class="form-control" name="F_310_CA" placeholder="First Name" required="">
<div class="error-message">First Name is required.</div>
</div>
<div class="col col-6"><label class="info-label">Last Name <span class="marked-required">*</span></label><input type="text" class="form-control" name="F_311_CB" placeholder="Last Name" required="">
<div class="error-message">Last Name is required.</div>
</div>
</div>
<div class="row mb-2">
<div class="col col-6"><label class="info-label">Date of Birth <span class="marked-required">*</span></label>
<div class="input-wrapper">
<div style="position: relative;">
<div class="rdt">
<div><input type="text" class="form-control" placeholder="Date of Birth" name="F_304_C4" required="" value=""></div>
<div class="rdtPicker">
<div class="rdtDays">
<table>
<thead>
<tr>
<th class="rdtPrev"><span>‹</span></th>
<th class="rdtSwitch" colspan="5" data-value="10">November 2024</th>
<th class="rdtNext"><span>›</span></th>
</tr>
<tr>
<th class="dow">Su</th>
<th class="dow">Mo</th>
<th class="dow">Tu</th>
<th class="dow">We</th>
<th class="dow">Th</th>
<th class="dow">Fr</th>
<th class="dow">Sa</th>
</tr>
</thead>
<tbody>
<tr>
<td data-value="27" class="rdtDay rdtOld">27</td>
<td data-value="28" class="rdtDay rdtOld">28</td>
<td data-value="29" class="rdtDay rdtOld">29</td>
<td data-value="30" class="rdtDay rdtOld">30</td>
<td data-value="31" class="rdtDay rdtOld">31</td>
<td data-value="1" class="rdtDay">1</td>
<td data-value="2" class="rdtDay">2</td>
</tr>
<tr>
<td data-value="3" class="rdtDay">3</td>
<td data-value="4" class="rdtDay">4</td>
<td data-value="5" class="rdtDay">5</td>
<td data-value="6" class="rdtDay">6</td>
<td data-value="7" class="rdtDay">7</td>
<td data-value="8" class="rdtDay">8</td>
<td data-value="9" class="rdtDay">9</td>
</tr>
<tr>
<td data-value="10" class="rdtDay">10</td>
<td data-value="11" class="rdtDay">11</td>
<td data-value="12" class="rdtDay">12</td>
<td data-value="13" class="rdtDay">13</td>
<td data-value="14" class="rdtDay">14</td>
<td data-value="15" class="rdtDay">15</td>
<td data-value="16" class="rdtDay rdtToday">16</td>
</tr>
<tr>
<td data-value="17" class="rdtDay">17</td>
<td data-value="18" class="rdtDay">18</td>
<td data-value="19" class="rdtDay">19</td>
<td data-value="20" class="rdtDay">20</td>
<td data-value="21" class="rdtDay">21</td>
<td data-value="22" class="rdtDay">22</td>
<td data-value="23" class="rdtDay">23</td>
</tr>
<tr>
<td data-value="24" class="rdtDay">24</td>
<td data-value="25" class="rdtDay">25</td>
<td data-value="26" class="rdtDay">26</td>
<td data-value="27" class="rdtDay">27</td>
<td data-value="28" class="rdtDay">28</td>
<td data-value="29" class="rdtDay">29</td>
<td data-value="30" class="rdtDay">30</td>
</tr>
<tr>
<td data-value="1" class="rdtDay rdtNew">1</td>
<td data-value="2" class="rdtDay rdtNew">2</td>
<td data-value="3" class="rdtDay rdtNew">3</td>
<td data-value="4" class="rdtDay rdtNew">4</td>
<td data-value="5" class="rdtDay rdtNew">5</td>
<td data-value="6" class="rdtDay rdtNew">6</td>
<td data-value="7" class="rdtDay rdtNew">7</td>
</tr>
</tbody>
</table>
</div>
</div>
</div><img src="/copayclient/images/icon-calendar.png" class="icon">
</div><span class="input-error" style="color: rgb(241, 115, 107); font-size: 10px;"></span>
</div>
<div class="error-message">Date of Birth is required.</div>
</div>
<div class="col col-6"><label class="info-label">Gender <span class="marked-required">*</span></label>
<div class="custom-select css-2b097c-container">
<div class=" css-spersy-control">
<div class=" css-1hwfws3">
<div class=" css-1wa3eu0-placeholder">Gender</div>
<div class="css-1g6gooi">
<div class="" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="react-select-2-input" spellcheck="false" tabindex="0" type="text" aria-autocomplete="list" name="F_305_C5"
required="" data-placeholder="Gender" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 14.4px; font-family: "Encode Sans Condensed", sans-serif; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class=" css-1wy0on6"><span class=" css-1okebmr-indicatorSeparator"></span>
<div aria-hidden="true" class=" css-tlfecz-indicatorContainer"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-19bqh2r">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div><input name="F_305_C5" type="hidden" value="">
</div>
<div class="error-message">Gender is required.</div>
</div>
</div>
<div class="row mb-2">
<div class="col col-12"><label class="info-label">Street Address <span class="marked-required">*</span></label><input type="text" class="form-control" name="F_322_CM" placeholder="Street Address" required="">
<div class="error-message">Street Address is required.</div>
</div>
</div>
<div class="row mb-2">
<div class="col col-6"><label class="info-label">Zip Code <span class="marked-required">*</span></label><input type="text" class="form-control" name="F_325_CP" placeholder="Zip Code" required="" value="">
<div class="error-message">Zip Code is required.</div>
</div>
<div class="col col-6"><label class="info-label">City <span class="marked-required">*</span></label><input type="text" class="form-control" name="F_323_CN" placeholder="City" required="">
<div class="error-message">City is required.</div>
</div>
</div>
<div class="row mb-2">
<div class="col col-6"><label class="info-label">State <span class="marked-required">*</span></label>
<div class="custom-select css-2b097c-container">
<div class=" css-spersy-control">
<div class=" css-1hwfws3">
<div class=" css-1wa3eu0-placeholder">State</div><input id="react-select-3-input" readonly="" tabindex="0" aria-autocomplete="list" class="css-62g3xt-dummyInput" value="">
</div>
<div class=" css-1wy0on6"><span class=" css-1okebmr-indicatorSeparator"></span>
<div aria-hidden="true" class=" css-tlfecz-indicatorContainer"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-19bqh2r">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div><input name="F_324_CO" type="hidden" value="">
</div>
<div class="error-message">State is required.</div>
</div>
<div class="col col-6"><label class="info-label">Phone Number <span class="marked-required">*</span></label><input type="text" class="form-control" name="F_326_CQ" placeholder="Phone Number" required="" value="">
<div class="error-message">Phone Number is required.</div>
</div>
</div>
<div class="row mb-2">
<div class="col col-12"><label class="info-label">Email Address <span class="marked-required">*</span></label><input type="email" class="form-control" name="F_350_HN" placeholder="Email Address" required="">
<div class="error-message">Email Address is required.</div>
</div>
</div>
</div>
</div>
</div>
<div class="btn-group text-right my-4"><button class="btn btn-primary"><span>Next</span></button></div>
</form><form><input type="hidden" name="enrollment_id"><input type="hidden" name="program" value="PYS"><input type="hidden" name="patient_id">
<div class="form mt-2">
<div class="row">
<div class="col-md-12">
<div class="form-title">2. Program Eligibility</div>
<p class="description">Program Eligibility.</p>
</div>
</div>
<div class="card no-overflow">
<div class="container">
<div class="row">
<div class="col-md-12">
<div class="row question-item align-items-center">
<div class="col-12">
<div class="question">Was TAGRISSO prescribed?<span class="marked-required"> *</span></div>
</div>
<div class="col">
<div class="custom-radio-button flex-start"><label class="radio-btn-container"><input type="radio" name="question[1524]" required="" value="Yes"><span class="checkmark"></span><span class="label">YES</span></label><label
class="radio-btn-container"><input type="radio" name="question[1524]" required="" value="No"><span class="checkmark"></span><span class="label">NO</span></label></div>
<div class="error-message">Please select an answer.</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="row question-item align-items-center">
<div class="col-12">
<div class="question">Is the Patient a current resident of the United States?<span class="marked-required"> *</span></div>
</div>
<div class="col">
<div class="custom-radio-button flex-start"><label class="radio-btn-container"><input type="radio" name="question[1526]" required="" value="Yes"><span class="checkmark"></span><span class="label">YES</span></label><label
class="radio-btn-container"><input type="radio" name="question[1526]" required="" value="No"><span class="checkmark"></span><span class="label">NO</span></label></div>
<div class="error-message">Please select an answer.</div>
</div>
</div>
</div>
<div class="col-md-6">
<div class="row question-item align-items-center">
<div class="col-12">
<div class="question">Are you at least 18 years old?<span class="marked-required"> *</span></div>
</div>
<div class="col">
<div class="custom-radio-button flex-start"><label class="radio-btn-container"><input type="radio" name="question[1525]" required="" value="Yes"><span class="checkmark"></span><span class="label">YES</span></label><label
class="radio-btn-container"><input type="radio" name="question[1525]" required="" value="No"><span class="checkmark"></span><span class="label">NO</span></label></div>
<div class="error-message">Please select an answer.</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="row question-item align-items-center">
<div class="col-12">
<div class="question">Is the Patient insured through a Commercial (also known as private) insurance health plan?<span class="marked-required"> *</span></div>
</div>
<div class="col">
<div class="custom-radio-button flex-start"><label class="radio-btn-container"><input type="radio" name="question[1527]" required="" value="Yes"><span class="checkmark"></span><span class="label">YES</span></label><label
class="radio-btn-container"><input type="radio" name="question[1527]" required="" value="No"><span class="checkmark"></span><span class="label">NO</span></label></div>
<div class="error-message">Please select an answer.</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="row question-item align-items-center">
<div class="col-12">
<div class="question">Is the Patient's prescription paid for in part or in full under any federally or state-funded programs, including but not limited to Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DOD, or Tricare?<span
class="marked-required"> *</span></div>
</div>
<div class="col">
<div class="custom-radio-button flex-start"><label class="radio-btn-container"><input type="radio" name="question[1528]" required="" value="Yes"><span class="checkmark"></span><span class="label">YES</span></label><label
class="radio-btn-container"><input type="radio" name="question[1528]" required="" value="No"><span class="checkmark"></span><span class="label">NO</span></label></div>
<div class="error-message">Please select an answer.</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<div class="row question-item align-items-center">
<div class="col-12">
<div class="question">I have appropriate authorization to enroll this patient in the Program and share patient information disclosed during this enrollment, including name, e-mail address, mailing address, and phone number, with
AstraZeneca, the sponsor of the Program, as well as parties working on behalf of AstraZeneca. The information shared will include the date that the patient filled the prescription, specifics about the medication dispensed by the
pharmacist, and out-of-pocket costs under the Program. I understand that, for the purpose of administering the Program, patients, practices, and pharmacies participating in the Program may be contacted by the Program administrator
to relay status or related matters. Program participation can be discontinued at any time by calling AstraZeneca Access 360 at 1-844-275-2360.<span class="marked-required"> *</span></div>
</div>
<div class="col">
<div class="custom-radio-button flex-start"><label class="radio-btn-container"><input type="radio" name="question[1529]" required="" value="Yes"><span class="checkmark"></span><span class="label">YES</span></label><label
class="radio-btn-container"><input type="radio" name="question[1529]" required="" value="No"><span class="checkmark"></span><span class="label">NO</span></label></div>
<div class="error-message">Please select an answer.</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="btn-group text-right my-4"><button class="btn btn-primary"><span>Next</span></button></div>
</form><form><input type="hidden" name="enrollment_id"><input type="hidden" name="program" value="PYS"><input type="hidden" name="patient_id">
<div class="form mt-2">
<div class="row">
<div class="col-md-12">
<div class="form-title">3. Terms And Conditions</div>
<p class="description">Terms and Conditions section.</p>
</div>
</div>
<div class="card no-overflow">
<div class="container">
<div class="row">
<div class="col-md-12">
<div class="row question-item align-items-center">
<div class="col-12">
<div class="question">Terms and Conditions<span class="marked-required"> *</span></div>
</div>
<div class="col col-12 terms_wrapper">
<div class="terms_container">
<p>“Eligible patients with an activated co-pay card and a valid prescription may pay as little as $0 per 30-day supply; monthly and annually, and/or per-claim maximum program benefits may apply and may vary from patient to patient,
depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, as solely based on factors determined solely by AstraZeneca. <br><br> Some prescription drug plans
have established programs referred to as ‘co-pay maximizer’ or ‘co-pay accumulator’ programs. Co-pay maximizer and co-pay accumulator programs are ones in which the amount of the patient’s out-of-pocket costs is adjusted to
reflect the availability of support offered by the co-pay support program. Patients enrolled in a co-pay maximizer or a co-pay accumulator program may receive varied program benefits to ensure the program funds are used for the
benefit of the patient.<br><br> AstraZeneca will monitor program utilization data and reserves the right to vary or discontinue program benefits at any time if AstraZeneca determines that patients are subject to a co-pay maximizer
or co-pay accumulator program. Any potential program re-enrollment may be subject to similar program restrictions based on patient’s prescription drug plan.<br><br> Other restrictions may apply. Patient is responsible for
applicable taxes, if any. Patient must be enrolled in the program before use. If you have any questions regarding this offer, please call 1-844-ASK-A360 (1-844-275-2360).<br><br> Non-transferable, 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.<br><br> Offer is invalid for claims or transactions more than 365 days from the date of service. A valid prescription must accompany Patient Savings Program offer.<br><br> BY USING THIS PROGRAM, YOU
AND YOUR PHARMACIST AND/OR PHYSICIAN UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.</p>
</div>
<div class="custom-checkbox-container"><label class="checkbox-container disabled"><span class="label">I AGREE</span><input type="checkbox" name="question[1407]" required="" placeholder="Terms and Conditions" data-placeholder="<p>“Eligible patients with an activated co-pay card and a valid prescription may pay as little as $0 per 30-day supply; monthly and annually, and/or per-claim maximum program benefits may apply and may vary from patient to patient, depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, as solely based on factors determined solely by AstraZeneca. <br>
Some prescription drug plans have established programs referred to as ‘co-pay maximizer’ or ‘co-pay accumulator’ programs. Co-pay maximizer and co-pay accumulator programs are ones in which the amount of the patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by the co-pay support program. Patients enrolled in a co-pay maximizer or a co-pay accumulator program may receive varied program benefits to ensure the program funds are used for the benefit of the patient.<br>
AstraZeneca will monitor program utilization data and reserves the right to vary or discontinue program benefits at any time if AstraZeneca determines that patients are subject to a co-pay maximizer or co-pay accumulator program. Any potential program re-enrollment may be subject to similar program restrictions based on patient’s prescription drug plan.<br>
Other restrictions may apply. Patient is responsible for applicable taxes, if any. Patient must be enrolled in the program before use. If you have any questions regarding this offer, please call 1-844-ASK-A360 (1-844-275-2360).<br>
Non-transferable, 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.<br>
Offer is invalid for claims or transactions more than 365 days from the date of service.
A valid prescription must accompany Patient Savings Program offer.<br>
BY USING THIS PROGRAM, YOU AND YOUR PHARMACIST AND/OR PHYSICIAN UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.</P>" disabled="" value="null"><span class="checkmark"></span></label></div>
<div class="error-message">You must agree to the terms before proceeding.</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="btn-group text-right my-4"><button class="btn btn-primary"><span>Next</span></button></div>
</form>Text Content
You need to enable JavaScript to run this app. TAGRISSO PATIENT SAVING PROGRAM ENROLLMENT 1. Patient Support 2. Patient Enrollment 1 2 3 4 1. Basic Information Patient Basic Information. * Required field. First Name * First Name is required. Last Name * Last Name is required. Date of Birth * ‹November 2024›SuMoTuWeThFrSa27282930311234567891011121314151617181920212223242526272829301234567 Date of Birth is required. Gender * Gender Gender is required. Street Address * Street Address is required. Zip Code * Zip Code is required. City * City is required. State * State State is required. Phone Number * Phone Number is required. Email Address * Email Address is required. Next 2. Program Eligibility Program Eligibility. Was TAGRISSO prescribed? * YESNO Please select an answer. Is the Patient a current resident of the United States? * YESNO Please select an answer. Are you at least 18 years old? * YESNO Please select an answer. Is the Patient insured through a Commercial (also known as private) insurance health plan? * YESNO Please select an answer. Is the Patient's prescription paid for in part or in full under any federally or state-funded programs, including but not limited to Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DOD, or Tricare? * YESNO Please select an answer. I have appropriate authorization to enroll this patient in the Program and share patient information disclosed during this enrollment, including name, e-mail address, mailing address, and phone number, with AstraZeneca, the sponsor of the Program, as well as parties working on behalf of AstraZeneca. The information shared will include the date that the patient filled the prescription, specifics about the medication dispensed by the pharmacist, and out-of-pocket costs under the Program. I understand that, for the purpose of administering the Program, patients, practices, and pharmacies participating in the Program may be contacted by the Program administrator to relay status or related matters. Program participation can be discontinued at any time by calling AstraZeneca Access 360 at 1-844-275-2360. * YESNO Please select an answer. Next 3. Terms And Conditions Terms and Conditions section. Terms and Conditions * “Eligible patients with an activated co-pay card and a valid prescription may pay as little as $0 per 30-day supply; monthly and annually, and/or per-claim maximum program benefits may apply and may vary from patient to patient, depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, as solely based on factors determined solely by AstraZeneca. Some prescription drug plans have established programs referred to as ‘co-pay maximizer’ or ‘co-pay accumulator’ programs. Co-pay maximizer and co-pay accumulator programs are ones in which the amount of the patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by the co-pay support program. Patients enrolled in a co-pay maximizer or a co-pay accumulator program may receive varied program benefits to ensure the program funds are used for the benefit of the patient. AstraZeneca will monitor program utilization data and reserves the right to vary or discontinue program benefits at any time if AstraZeneca determines that patients are subject to a co-pay maximizer or co-pay accumulator program. Any potential program re-enrollment may be subject to similar program restrictions based on patient’s prescription drug plan. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Patient must be enrolled in the program before use. If you have any questions regarding this offer, please call 1-844-ASK-A360 (1-844-275-2360). Non-transferable, 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 is invalid for claims or transactions more than 365 days from the date of service. A valid prescription must accompany Patient Savings Program offer. BY USING THIS PROGRAM, YOU AND YOUR PHARMACIST AND/OR PHYSICIAN UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE. I AGREE You must agree to the terms before proceeding. Next Success! * * BIN: * ID: * GROUP: * PCN: Next OK You may report side effects related to AstraZeneca products by clicking here This site is intended for US audience only. TAGRISSO is a registered trademark and AstraZeneca Access 360 is a trademark of the AstraZeneca group of companies. All other trademarks are the property of their respective owners. ©2023 AstraZeneca. All rights reserved. US-79093 Last Updated 9/23 * Terms & Conditions * Privacy Policy * Prescribing Information * Contact Us