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Program Details

TEVA PHARMACEUTICALS
Teva Cares Foundation

ProAir Hfa inhaler (albuterol hfa)
 
CONTACT INFO
Address: PO Box 52028
Phoenix, AZ 85072-9937
Phone: 1-877-254-1039 Provider Phone:
Fax: 1-888-782-6157 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must not have prescription coverage for the medication. (Discount cards are not considered insurance.)
  • Patient's who have reached their insurance cap are able to apply.
  • Income at or below: Single 200 % FPL
      Couple 200 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Patient Consent Form
    Physician License #
    Required:
    Both DEA and State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Provider
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Not Published
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    Refill Policy: Physician's office must contact the program to arrange refills.
    Other Information:

    Last Updated: 09/04/2013

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)



     

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