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Imogam and ImoVax Patient Assistance Program
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C/O NORD
PO Box 1968
Danbury, CT 06813-1968
Phone
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877-798-8716
Fax:
203-798-2964
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Eligibility
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The patient must have no prescription coverage for the requested medication and have a low income based on the Federal Poverty Guidelines. The patient must also be a US resident. |
| 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 and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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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.
| | Imovax Rabies IM (Rabies Vaccine) |
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Sanofi Patient Connection
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PO Box 222138
Charlotte, NC 28222
Phone
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(888)847-4877
Fax:
(888)847-1797
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Eligibility
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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
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Anyone requesting assistance may call to request an application. |
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Required
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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. |
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Supply
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A 30 to 90 day supply will be sent, depending on the medication. |
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Ship To
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The medication will be shipped to the doctor's office. |
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Note
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For refills, a reorder form must be faxed to Sanofi Patient Connection. A new application is required once a year. |
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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.
| | Imovax Rabies IM (Rabies Vaccine) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | (Requires Acrobat Reader) 
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Sanofi Patient Connection Program
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PO Box 222138
Charlotte, NC 28222
Phone
:
888-847-4877
Fax:
888-847-1797
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Eligibility
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Patients must have no prescription insurance and be ineligible for any state and federal programs. Medicare Part D recipients will be considered on an exception basis. Patients must be at or below 500% of FPL for oncology products and at or below 250% of FPL for all other products. Patients must also have a medically appropriate condition/diagnosis and have a social security number. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income. |
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Supply
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Varies |
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Ship To
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Doctor's office |
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Note
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Negative decision may be appealed. Insurance benefits, claims assistance and/or other reimbursement help is offered. Exceptions to guidelines considered.
Patients who do not file taxes must either request a 4506-T form from the IRS, submit proof of benefits received (such as Social Security) Earning Statement, or submit W2's of the person who is supporting them financially.
Healthcare provider must contact the Program for REORDER FORMS.
*On most medications, excluding Lovenox, patients with Medicare Part D may be considered if they are not eligible for Low Income Subsidy, and they have spent at least 5% of annual household income on out-of-pocket costs for medications. |
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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.
| | Imovax Rabies IM (Rabies Vaccine) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | Download printable Form | | (Requires Acrobat Reader)
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