Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

Sanofi Patient Connection Program

This program provides brand name medications at no or low cost

Provided by: Sanofi-Aventis U.S. LLC

PO Box 222138
Charlotte, NC 28222-2138

TEL: 888-847-4877


ALT PHONE: 800-221-4025
FAX: 888-847-1797 		Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Sanofi-Aventis Patient Assistance Program Application
 

Medications
  • Adacel injection (tetanus toxoid/reduced diptheria toxoid/acellular pertussis)
 

Eligibility Requirements   
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
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
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
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.


Updated September 14, 2017