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Patient Assistance Information

 
3 Programs for Synagis (palivizumab)
 
 
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)
 
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US.
Who Can Apply
> Patients or healthcare providers can complete the application online or by phone.
Required
> Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
 
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)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
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)