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Patient Assistance Information

 
1 Program for Apidra (insulin glulisine [rDNA origin] injection)
 
 
Sanofi Patient Connection

PO Box 222138
Charlotte, NC 28222
Phone : (888)847-4877
Fax: (888)847-1797
Eligibility
> An application must be submitted for each patient. They can be submitted via fax, or mail. The patient must be a US citizen or resident, with a Social Security Number. The patient must be under the care of a licensed healthcare provider who is authorized to prescribe, dispense and administer medicine in the US. The patient must have an income at or below 500% of the FPL for oncology and hematology products and at or below 250% for all other products. For Vaccines, patient must be 19 years of age or older (except IMOVAX RABIES and IMOGAM RABIES HT).
Who Can Apply
> Anyone requesting assistance may call to request an application.
Required
> The application must be completed and signed by both the patient and by the healthcare provider. Proof of income must also be submitted which includes a copy of the most recently filed US Income Tax Return, a copy of a W-2, or most recent Social Security statement.
Supply
> A 30 to 90 day supply will be sent, depending on the medication.
Ship To
> The medication will be shipped to the doctor's office.
Note
> For refills, a reorder form must be faxed to Sanofi Patient Connection. A new application is required once a year.
 
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.
 
Apidra Injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader