CONTACT
INFO |
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Address: |
, |
Phone: |
1-866-613-4724 |
Provider Phone: |
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Fax: |
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Website: |
Program Website |
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ELIGIBILITY
|
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Eligibility
Info: |
Applications are reviewed on a case-by-case basis.
Patients who have insurance, but medication is not covered might still be eligible for this program.
Program also provides co-pay assistance. |
|
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 |
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Attachments
Required: |
Financial
|
Physician
License #
Required: |
DEA
NPI
Facility License number
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
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MEDICATION |
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Receives: |
Medication
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Shipped To: |
Provider
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Quantity in
Shipment: |
Not Published
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Delivery Time: |
0-1 week
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Re-application
Policy: |
New application every 12 months
New financial information every 12 months
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Refill Policy: |
Physician's office must contact the program |
Other Information: |
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