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Program Details

SANOFI
Sanofi Patient Connection

Lantus (insulin glargine)
 
CONTACT INFO
Address: PO Box 222138
Charlotte, NC 28222-2138
Phone: 1-888-847-4877 Provider Phone:
Fax: 1-888-847-1797 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • This program offers Reimbursement, Resource and Patient Assistance information.
  • Must not have prescription coverage and must not be eligible for state or federal programs such as Medicare and Medicaid.
  • Patients with Medicare Part D might be considered if they are ineligible for Low Income Subsidy and have spent at least 5% of their annual household income (out of pocket) on medications.
  • Paient must be under the care of a licensed healthcare provider who is authorized to prescribe, dispense, and administer medicine in the US.
  • For Vaccines, paient must be at least 19 years of age.
  • Income at or below: Single % FPL
      Couple % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Other Income Requirements: Annual household income of <500% of FPL for oncology products and <250% for all other eligible PAP products.
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Financial Documents: copy of recent tax return, copy of W-2 or copy of Social Security/Disability monthly check or most recent Social Security Statement
    Physician License #
    Required:
    State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Only Rilutek can be shipped directly to patient.
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy:
    Refill Policy: A refill form must be faxed to program.
    Other Information:
  • If paient is uninsured, check box 2 under Section IV: Reimbursement Connection.
  • Last Updated: 07/07/2014

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)



     

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