| CONTACT
INFO |
|
| Address: |
PO Box 2355
Morristown, NJ 07962 |
| Phone: |
1-833-274-8684 |
Provider Phone: |
|
| Fax: |
|
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Contact program for details.
Patient must be a permanent US resident
Income guidelines are based on fixed annual gross household income per household size. See guidelines below. |
| Income at or below: |
Single |
100,000 |
% FPL |
| |
Couple |
150,000 |
% FPL |
| Income at or below: |
Not
Published |
| Other Income
Requirements: |
$25k for each additional household member |
| Medical expenses
can be deducted from reported income: |
No
|
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Patient Consent Form
|
Physician
License #
Required: |
State
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
|
| MEDICATION |
|
| Receives: |
Pharmacy Card
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|