CONTACT
INFO |
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Address: |
PO Box 16130
Columbus, OH 43216 |
Phone: |
1-877-237-4881 |
Provider Phone: |
|
Fax: |
1-877-438-4404 |
Website: |
Program Website |
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ELIGIBILITY
|
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Eligibility
Info: |
Patient must not have prescription coverage for the medication and meet program income guidelines which are not disclosed.
Patients with Medicare Part D are not eligible.
Call for current medication list as is subject to change.
|
|
Couple |
|
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
Yes |
US citizenship/residency specified:
|
Yes |
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APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Either Provider and Patient
|
Quantity in
Shipment: |
Varies by medication |
Delivery Time: |
0-1 week
|
Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
Refill Policy: |
Reorder form must be sumbitted |
Other Information: |
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