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Patient Assistance Information

 
 
 
MAP

MAP
P. O. Box 222197
Charlotte, NC 28222-2197
Phone : (877) 480-8082
Fax: (877) 675-6513
Eligibility
> Patient must have no form of health insurance and meet program's income guidelines.
Who Can Apply
> Physician's office must call on patient's behalf.
Required
> Provider must complete product request form on a monthly basis.
Supply
> One cycle
Ship To
> Physician's office.
Note
> Faxed applications are accepted. Patient must re-apply if income or insurance status changes.
 
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)