Zaltrap Patient Assistance Programs

Zaltrap: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Zaltrap. 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 PharmacyChecker.com) or go to the program website.

Looking for a different medication?

Sanofi Patient Connection Program

(Program 1 of 2 — 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
Medications
  • Zaltrap (ziv-aflibercept)
Eligibility Requirements
  • Insurance Status Must have no prescription insurance, be ineligible for any state and federal programs
  • Those with Part D Elibible? 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
  • U.S. Residency Required? Must be a US citizen or permanent resident and treated by a US licensed healthcare provider
Application
  • 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
Medication
  • 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. *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 April 8, 2019

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Patient Access Network Foundation (PAN)

(Program 2 of 2 — Scroll down to see them all )

Provided by: Patient Access Network Foundation
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Zaltrap (ziv-aflibercept)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
  • U.S. Residency Required? Must reside and receive treatment in US
Application
  • Obtaining Call or complete online
  • Receiving Complete online or by phone
  • Returning Complete online or by phone
  • Doctor's Action Will be discussed with patient and Doctor after request is received
  • Applicant's Action Call for information or inform doctor that he/she is in need
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe Within 48 hours
Medication
  • Amount/Supply Not applicable
  • Sent To Patient sent card to be used at pharmacy
  • Delivery Time Once approved; shipped same day
  • Refill Proces Patient presents voucher/card to pharmacy for each refill
  • Limit None
  • Re-application New application every 12 months
Additional Information
*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
Updated January 4, 2019

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