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Patient Assistance Information

 
 
 
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)