CONTACT
INFO |
|
Address: |
P.O. Box 500227
San Diego, CA 92150 |
Phone: |
1-877-448-4766 |
Provider Phone: |
|
Fax: |
1-888-354-4856 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be uninsured and meet program income guidelines which are not disclosed.
Patients with Medicare Part D are not eligible.
Program offers reimbursement assistance, patient support, and patient assistance programs for eligible patients.
|
|
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: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Provider
|
Quantity in
Shipment: |
Not Published
|
Delivery Time: |
Not Published
|
Re-application
Policy: |
New application needed
|
Refill Policy: |
Reorder form needs to be submitted. |
Other Information: |
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