CONTACT
INFO |
|
Address: |
PO Box 991624
Louisville, KY 40269 |
Phone: |
1-833-862-8727 |
Provider Phone: |
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Fax: |
1-844-705-0160 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be a legal United States resident.
Must have a valid prescription from a licensed U.S. healthcare professional for a product made available through the Bausch Health PAP.
Patient must not have insurance coverage for the prescribed Bausch Health product.
Eligibility for patients with Medicare Part D are determined on case-by-case basis.
Meet the pre-defined eligibility requirements and total annual household income requirements. |
|
Couple |
|
% FPL |
|
Credit
for Dependents allowed |
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: |
Both Provider and Patient
|
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MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Either Provider and Patient
|
Quantity in
Shipment: |
Varies |
Delivery Time: |
Not Published
|
Re-application
Policy: |
New application every 12 months
|
Refill Policy: |
Not Published
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Other Information: |
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