CONTACT
INFO |
|
Address: |
PO Box 5428
Williamsburg, VA , VA 23188 |
Phone: |
1-888-474-3657 |
Provider Phone: |
|
Fax: |
1-866-557-8706 |
Website: |
Program Website |
|
ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be uninsured.
Patients with Medicare Part D are not eligible. |
Income at or below: |
Single |
|
250
% FPL |
|
Couple |
|
250
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
Yes |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
Both DEA and State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Not Published
|
Quantity in
Shipment: |
1 dose |
Delivery Time: |
Not Published
|
Re-application
Policy: |
Not Published |
Refill Policy: |
Not Published
|
Other Information: |
|
|