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Patient Assistance Information

 
3 Programs Sponsored By MedImmune, Inc (External Link)
 
 
Synagis Patient Assistance Program

PO Box 222197
Charlotte, NC 28222-2197
Phone : 877-480-8082
Fax: 877-675-6513
Eligibility
> 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
> The doctor/doctor's office must call for a prescreening.
Required
> 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.
Supply
> Up to a 30-day supply
Ship To
> Doctor's office
Note
> The doctor/doctor's office must call for a prescreening.
 
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.
 
Synagis (palivizumab)
 
 
 
Ethyol Protect Program

PO Box 222197
Charlotte, NC 28222-2197
Phone : 800-887-2467
Fax: 877-675-6513
Eligibility
> The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be a US resident.
Who Can Apply
> The doctor/doctor's office should call for an application.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income.
Supply
>
Ship To
> Doctor's office
Note
> The doctor/doctor's office should call for an application.
 
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.
 
Ethyol (amifostine)
Neutrexin (trimetrexate glucuronate)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
MAP

MAP
P. O. Box 222197
Charlotte, NC 28222-2197
Phone : (877) 480-8082
Fax: (877) 675-6513
Eligibility
> Patient must have no form of health insurance and meet program's income guidelines.
Who Can Apply
> Physician's office must call on patient's behalf.
Required
> Provider must complete product request form on a monthly basis.
Supply
> One cycle
Ship To
> Physician's office.
Note
> Faxed applications are accepted. Patient must re-apply if income or insurance status changes.
 
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.
 
Synagis (palivizumab)