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Patient Assistance Information

 
1 Program for Menactra Meningococcal (Groups A, C, Y and W-135) Vaccine
 
 
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.
 
Menactra Meningococcal (Groups A, C, Y and W-135) Vaccine
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader