CONTACT
INFO |
|
Address: |
, |
Phone: |
1-844-387-4936 |
Provider Phone: |
|
Fax: |
1-844-387-3970 |
Website: |
Program Website |
|
ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be uninsured or underinsured.
Patients with Medicare Part D should contact the program.
Program also providers co-pay assistance.
|
|
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: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
|
MEDICATION |
|
Receives: |
Varies
|
Shipped To: |
Patient
|
Quantity in
Shipment: |
Not Published
|
Delivery Time: |
Not Published
|
Re-application
Policy: |
New application every 12 months
|
Refill Policy: |
Not Published
|
Other Information: |
|
|