| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-866-538-7879 |
Provider Phone: |
|
| Fax: |
|
Website: |
Fertility LifeLines |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must call program for prescreening before application is sent.
Patient must not have insurance and meet program income guidelines which are not disclosed.
Patient must currently be undergoing treatment with a doctor familiar with infertility management.
Fertility Assist will help pay for fertility medications for patients who have not been successful after two prior attempts that include Gonal-f. The patient must have paid cash for the first two attempts through the Freedom Fertility Pharmacy and have filled their prescription for the third cycle within 18 months of the first perscription.
Filling the prescription through the Freedom Fertility Pharmacy automatically enrolls the patient.
|
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security
# requested on form: |
Not
Published |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Not Published
|
Physician
License #
Required: |
Not Published
|
Prescriber
Signature
Allowed: |
Not Published
|
Application
may be
faxed: |
No |
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Not Published
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
One time program
|
| Refill Policy: |
No refills
|
| Other Information: |
|
|
