CONTACT
INFO |
|
Address: |
PO Box 5637
Louisville, KY 40255 |
Phone: |
1-855-297-5906 |
Provider Phone: |
|
Fax: |
1-855-297-5907 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be uninsured or underinsured.
Medicare Part D patients may be eligible, contact program for details. |
|
Couple |
|
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
No |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Patient
|
Quantity in
Shipment: |
Up to 60-days |
Delivery Time: |
Not Published
|
Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
Refill Policy: |
Physician's or Patient must contact program for refills |
Other Information: |
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