| |
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.
|
| Adacel (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|