Contact info
- Phone
- 1-888-941-3331
- Fax
- 1-833-999-4363
Eligibility
- Eligibility is determined on a case-by-case basis.
- Patient must be uninsured or underinsured with no prescription coverage for needed medication.
- Income limit, single
- $75,000 a year
- Income limit, couple
- $100,000 a year
- Other income rules
- Add $25,000 for each extra person in household
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- US citizenship or residency required
- Not published
Not sure where your income falls? See this year's federal poverty guidelines (opens in a new tab).
Application process
- Documents to attach
- Proof of income
- Prescriber license number
- NPI number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider and patient
Getting the medication
- Patient receives
- Medication
- Shipped to
- Patient
- Supply per shipment
- Varies
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Actemra (tocilizumab)
- Activase (alteplase)
- Alecensa (alectinib)
- Avastin (bevacizumab)
- Cathflo (alteplase)
- Columvi (glofitamab-gxbm)
- Cotellic (cobimetinib)
- Enspryng injection (satralizumab-mwge)
- Erivedge (vismodegib)
- Evrysdi (risdiplam)
- Gazyva (obinutuzumab)
- Hemlibra (emicizumab-kxwh)
- Herceptin (trastuzumab)
- Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)
- ITOVEBI (Inavolisib)
- Kadcyla (ado-trastuzumab emtansine)
- Lucentis (ranibizumab injection)
- Lunsumio (mosunetuzumab-axgb)
- Ocrevus (ocrelizumab)
- Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq)
- PERJETA (pertuzumab)
- Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
- PiaSky (crovalimab-akkz)
- Polivy (polatuzumab vedotin-piiq)
- Pulmozyme (dornase alfa recombinant inhalation solution)
- Rituxan (rituximab)
- Rituxan Hycela (rituximab/hyaluronidase human)
- Rozlytrek (entrectinib)
- Susvimo (ranibizumab)
- Tecentriq (atezolizumab)
- Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs)
- TNKase (tenecteplase)
- Vabysmo (faricimab-svoa)
- Venclexta (venetoclax)
- Xolair (omalizumab)
- Zelboraf (vemurafenib)