Program Contact Info / Application Submission
Program	Synagis Assistance Program
Company	MedimmuneMAP
Address	PO Box 222197 Charlotte, NC 28222-2197
Phone	877-480-8082 opt5
Fax	877-675-6513
Website	http://www.synagis.com/insurance.aspx
Program Requirements
Details	Insurance card NOT required Drivers license NOT required
Delivery of Medication
Ship Time	7 - 10 business days
Delivery Options	Can NOT be delivered directly to the patient Can be delivered directly to the doctor
Application Process
New Applications	New applications accepted Patients can NOT apply directly to the program Doctors can apply directly to the program Advocates can NOT apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail
Re-Applications	Re-Applications accepted Patients can NOT apply for Re-Applications Doctors can apply for Re-Applications Advocates can NOT apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals NOT accepted Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail
Eligibility
Limitations	Patients are NOT eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are NOT eligible if prescription is not covered Patients are NOT eligible if prescription coverage has been exhausted Patients are NOT eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted
Appeals
Conditions	Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied
Other Medications
Other  Medications  available in  this program	RespiGam - Immune (Generic: RSV immune globulin) Synagis 50mg vial for injection - Immune (Generic: palivizumab) Synagis 100mg vial for injection - (Generic: )