| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-833-965-1620 |
Provider Phone: |
|
| Fax: |
1-833-965-1621 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be uninsured (no insurance) or underinsured (insurance does not cover medication).
Patient must meet financial requirements to qualify for Medicaid or have Medicaid coverage where the product is not covered
Patients with Medicare Part D and are not eligible. |
| |
Couple |
|
% 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
Prescription
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Provider
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
Not Published
|
| Other Information: |
|
|