This component of the program is made possible through Sanofi Cares North America. How to Apply: Select one of the links below to download the application or go to the program site for more information on how to apply. Adverse reactions of hydroxychloroquine Chloroquine phosphate administration Hydroxychloroquine combination Plaquenil withdrawal headache C3 independent non-profit organization providing financial assistance to adults and children to cover the cost of prescription drug coinsurance, copayments, deductibles, health insurance premiums and other selected out-of-pocket health care costs. Need assistance with medication co-pay Insurance company has denied payment of treatment medication Please remember that all assistance programs will need to see a valid, current prescription from a physician in order to complete your application for possible approval. Upon receipt of completed application, prescription from physician, and approval of application, medication will be shipped directly to the physician's office from the distribution center. The patient is eligible for assistance for 12 months. Patient's total annual household income must be below 250% of the Federal Poverty Line. Once you fill out your application, send it to the address on the application. Eligibility: Patient must be a legal resident of the United States. Plaquenil prescription assistance programs Drug Name Brand Name Manufacturer Program Contact Information, Prescription assistance programs Lupus Foundation of America Plaquenil maculopathy symptomsHow is hydroxychloroquine side effects Pharmaceutical Assistance Program. Some pharmaceutical companies offer assistance programs for the drugs they manufacture. Click on the first letter of your drug name to see if any programs are available for the drugs you are taking. If your drug is on the list, click on "details" for detailed information about the program. Pharmaceutical Assistance Program - Medicare. Sanofi-Aventis Patient Assistance Program -. BMS 207 PAF Application-Form RD7. Coupon Value and Save Save between 10%-75% on Plaquenil prescription. With this Plaquenil Rebate Card, Price for 30 tablets of Plaquenil 200mg is from $118.65–$145.19. Price for 30 tablets of hydroxychloroquine 200mg generic is from $8.27–$9.92. This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level. The patient must be getting treatment for systemic lupus erythematosus. The patient must have health insurance that covers his or her qualifying medication or product. The patient’s medication or product must be listed on PAN’s list of covered medications. The patient’s income must fall at or below 500% of the Federal Poverty Level.