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Synagis Patient Assistance Program
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PO Box 222197
Charlotte, NC 28222-2197
Phone
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877-480-8082
Fax:
877-675-6513
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Eligibility
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The patient must have no insurance and The patient must meet income guidelines that are not disclosed. The patient must also be a US citizen being treated by a US doctor. |
| Who Can Apply
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The doctor/doctor's office must call for a prescreening. |
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Required
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The doctor must fill out a section, sign the application and attach a copy of the DEA or State License number.The patient must fill out a section and sign the application. |
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Supply
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Up to a 30-day supply |
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Ship To
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Doctor's office |
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Note
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The doctor/doctor's office must call for a prescreening. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Synagis (palivizumab) |
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