Apply to Sanofi Patient Connection

Sanofi gives certain Sanofi medicines, including its insulins, free to people with limited income who are uninsured, on Medicare Part D, or whose insurance doesn't cover the medicine. Your answers stay in this browser; we never see them.

Who can apply?

Yearly household income before taxes, 2026 limits
Household1 person2 people3 people4 people
Yearly income up to$63,840$86,560$109,280$132,000

Medicare Part D qualifies on income. Commercial insurance only if the plan gives no access to the medicine. If you may be eligible for Medicaid, a Medicaid denial is needed first. VA and military coverage aren't addressed on the form: call to ask.

Your answers

Check each one. Signatures, dates and consent boxes stay blank for you to do by hand.

Medicine
Name and strength, e.g. Trulicity 1.5 mg. Goes on the note for your prescriber; they write the prescription.
You
Two letters, e.g. FL
10 digits
Household
Wages, Social Security, pensions, disability and any other income. 0 if none.
Coverage
Which health coverage do you have?
Helpers
Optional: a family member or caregiver.

Then what?

  1. Sign

    • HIPAA consent (page 2, signature 1 of 3)
    • Income verification (page 2, signature 2 of 3)

  2. Attach

    • A copy of each insurance card, front and back, if you have insurance

  3. Your prescriber

    • Completes and signs page 3 (the prescription)
    • Mails or faxes pages 2 and 3

  4. Send

    • Fax 1-888-847-1797 (The prescriber's office mails or faxes pages 2 and 3 only.)
    • Mail to Sanofi Patient Connection, PO Box 222138, Charlotte, NC 28222-2138

Questions: call Sanofi Patient Connection at 1-888-847-4877. 12 months, or through the end of the calendar year with Medicare Part D.

Free. Sanofi Patient Connection does not charge any fees for this service. EveryCard Rx isn't paid by the program and never sends anything for you. Form MAT-US-2109597-v7.0-04/2025, rules checked 2026-11-06 from the program's own pages. Something out of date? Tell us.