Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
Sanofi Patient Connection ProgramThis program provides brand name medications at no or low cost @if> |
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Provided by: Sanofi-Aventis U.S. LLC |
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PO Box 222138 TEL: 888-847-4877ALT PHONE: 800-221-4025 FAX: 888-847-1797 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Sanofi-Aventis Patient Assistance Program Application |
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Medications |
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Eligibility Requirements |
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Insurance Status | Must have no prescription insurance, be ineligible for any state and federal programs | ||
Those with Part D Eligible? | Considered on exception basis | ||
Income | At or below 500% of FPL for oncology products and at or below 250% of FPL for all other products | ||
Diagnosis/Medical Criteria | Medically appropriate condition/diagnosis | ||
US Residency Required? | Yes | ||
Application |
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Obtaining | Call or download | ||
Receiving | Faxed, mailed or downloaded from website | ||
Returning | Fax or mail | ||
Doctor's Action | Complete section and sign | ||
Applicant's Action | Complete section, sign, attach a copy of proof of income | ||
Decision Communicated | Patient and Doctor are notified | ||
Decision Timeframe | 2-4 business days | ||
Medication |
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Amount/Supply | Varies | ||
Sent To | Doctor's office | ||
Delivery Time | Within 2-4 business days | ||
Refill Process | Reorder form needs to be submitted | ||
Limit | None | ||
Re-application | New application, new documentation yearly | ||
Additional Information |
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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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Updated April 09, 2018 |