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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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Ethyol Protect Program
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PO Box 222197
Charlotte, NC 28222-2197
Phone
:
800-887-2467
Fax:
877-675-6513
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Eligibility
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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
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The doctor/doctor's office should call for an application. |
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Required
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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
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| > |
|
|
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.
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| Ethyol (amifostine) |
| Neutrexin (trimetrexate glucuronate) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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