If you are applying for assistance with SYNAGIS® (palivizumab), please refer to the checklist printed on the application for that product. Click here to download an application for SYNAGIS.
The following items must be submitted by mail or by fax to complete your application, even if you have completed the application online.
- A completed application, signed and dated by you and your prescriber.
- The completed prescription on page 3 of the application.
- Proof of household income (include only one of the following):
- A copy of the most recent federal income tax returns for yourself, your spouse, and dependents
- All income statements from jobs last year (W2 or 1099)
- Two current paystubs
- Current Social Security Income Yearly Benefits Statement (stating income you received from Social Security in the past year)
- If your current household income is zero, a letter explaining your financial situation from a family member, healthcare provider, or yourself
If you are a Medicare Part B or Part D enrollee, please also include:
- A copy of the front and back of your Medicare Rx card (for Part D) or your Medicare enrollment card (for Part B)
- A copy of your Medicare Part B and/or Medicare Part D Prescription Drug statement (Explanation of Benefits [EOB]), a pharmacy printout, or a summary document from your pharmacy indicating the amount you have spent on prescriptions in the current calendar year; this total should be at least 3% of your income.
If you’ve experienced recent financial hardship and your financial documentation from last year does not accurately reflect your current situation, you’ll need to include supporting documentation explaining how your circumstances have changed. These forms include:
- Employer or unemployment office letter
- A copy of a marriage certificate or divorce decree to explain a change in marital status
- A copy of a birth or death certificate to explain a change in household number