Pentacel Prescription Assistance Programs

Pentacel: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Pentacel. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not or go to the program website.

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Sanofi Patient Connection Program

(Program 1 of 1 — Scroll down to see them all )

Provided by: Sanofi-Aventis U.S. LLC
PO Box 222138 Charlotte, NC 28222-2138
TEL: 888-847-4877
FAX: 888-847-1797
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
  • Pentacel (diptheria and tetanus toxoids and acellular pertussis adsorbed inactivated poliovirus and haemophilus B conjugate tetanus toxoid conjugate vaccine)
Eligibility Requirements
  • Insurance Status Must have no prescription insurance, be ineligible for any state and federal programs
  • Those with Part D Elibible? Contact program for details.
  • Income At or below 400% of FPL
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
  • Obtaining Call or download
  • Receiving Faxed, mailed or downloaded from website
  • Returning The completed application can be faxed or mailed back.
  • 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
  • Amount/Supply Varies
  • Sent To Doctor's office
  • Delivery Time Within 2-4 business days
  • Refill Proces 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.
Updated December 9, 2019

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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