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ELIGIBILITY
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Eligibility
Info: |
Patient must not have insurance coverage and is being treated as an outpatient for one of the medications listed on application.
Patients with Medicare Part D must have spent at least 3% of yearly household income on out-of-pocket costs for prescriptions this year. |
|
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
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Provider
|
Quantity in
Shipment: |
Amount varies |
Delivery Time: |
0-1 week
|
Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
Refill Policy: |
The patient or doctor must contact the company for refills. |
Other Information: |
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