| Pharmaceutical Company | Aventis |
| Program Address | Aventis Pharmaceuticals PO Box 759 Somerville NJ 08876 |
| Toll Free Phone Number | 800-221-4025 |
| Fax Number | n/a |
| Guidelines and Notes | Patients must be US residents who don't qualify for any government or private insurance for prescriptions. Income must be less than $17,720/yr for a household of 1; $23,880/yr for 2; $30,040/yr for 3; $36,200/yr for 4; $42,360/yr for 5 and less than $48,520 for 6 or more. Latest form dated 5/09/02 in bottom left corner. |
| Initiating Enrollment | They will mail or fax their form and it can be copied or downloaded. |
| Health Provider's Role | Doctor completes, signs, and ATTACHES RX for up to a 90 day supply (except Lantus which is provided in minimum of 10 vial supply and in increments of 10). Pt. and physician will receive letter if application is denied. |
| Patient's Role | Income and insurance information needed. Proof of pt./household income required annually. Can be copy of most recent tax return or other proof of income. PATIENT SIGNATURE REQUIRED. |
| How Dispensed | Medication is sent to the prescriber. The patient's name will be on the mailing label, not the bottle. |
| Amount Dispensed | Varies by medication. Usually a three month supply. Takes 4 weeks for them to process and send the medication. |
| Refills | Use an entirely new application, just like first time. |
| Limit | Unspecified |