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MAP
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MAP
P. O. 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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Patient must have no form of health insurance and meet program's income guidelines. |
| Who Can Apply
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Physician's office must call on patient's behalf. |
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Required
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Provider must complete product request form on a monthly basis. |
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Supply
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One cycle |
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Ship To
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Physician's office. |
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Note
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Faxed applications are accepted. Patient must re-apply if income or insurance status changes. |
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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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