CONTACT
INFO |
|
Address: |
PO Box 220590
Charlotte, NC 28222-0590 |
Phone: |
1-866-728-4368 |
Provider Phone: |
|
Fax: |
1-855-474-3063 |
Website: |
Program Website |
|
ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be uninsured.
Patients with Medicare are not eligible.
For patient living in Puerto Rico - must not be eligible for Puerto Rico's Government Health Plan Mi Salud or have applied and been denied. |
Income at or below: |
Single |
|
300
% FPL |
|
Couple |
|
300
% 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: |
Not Published
|
Physician
License #
Required: |
State
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Provider
|
Quantity in
Shipment: |
Not Published
|
Delivery Time: |
Not Published
|
Re-application
Policy: |
Not Published |
Refill Policy: |
Not Published
|
Other Information: |
|
|