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| ELIGIBILITY
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| Eligibility
Info: |
Patient must be a US resident.
Patient must meet program income requirements which may vary by product and household size.
Patient must have limited or no private or public prescription coverage. |
| |
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:
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Yes |
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APPLICATION |
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| Attachments
Required: |
Financial
|
Physician
License #
Required: |
Both DEA and State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Provider
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| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
Note: For Clozaril, Focalin XR and Ritalin LA the patient will receive a pharmacy card.
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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
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| Refill Policy: |
Contact program for refills |
| Other Information: |
Additional products may be available. Please contact the program for a complete product listing. www.pap.novartis.com |
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