| CONTACT
INFO |
|
| Address: |
PO Box 222138
Charlotte, NC 28222-2138 |
| Phone: |
1-888-847-4877 |
Provider Phone: |
|
| Fax: |
1-888-847-1797 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must have no insurance coverage or access to the prescribed product or treatment via their insurance.
Patients with Medicare Part D may be eligible, contact program for details. |
| Income at or below: |
Single |
|
400
% FPL |
| |
Couple |
|
400
% 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 |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
Medicaid denial letter
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
A refill form must be faxed to program. |
| Other Information: |
|
|