| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-866-272-8838 |
Provider Phone: |
|
| Fax: |
1-866-272-8839 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must have no prescription coverage or been denied coverage and meet program income guidelines which are based on the federal poverty level.
Program will provide patient assistance referrals 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:
|
Not
Published |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Provider
|
|
| MEDICATION |
|
| Receives: |
Varies
|
| Shipped To: |
Not Published
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|