CONTACT
INFO |
|
Address: |
PO Box 501847
San Diego, CA 92150 |
Phone: |
1-800-545-6962 |
Provider Phone: |
|
Fax: |
1-844-431-6650 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be uninsured or have Medicare Part D.
Patients may be eligible if insurance does not cover their medication. Contact program for details.
Patients must not be eligible for or enrolled in Medicaid or Veterans Administration Benefits.
|
|
Couple |
|
% FPL |
Income at or below: |
Not
Published |
Other Income
Requirements: |
Income limits vary by medication. Contact program for details. |
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: |
DEA
State
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Either Provider and Patient
|
Quantity in
Shipment: |
Up to a 120-day supply |
Delivery Time: |
Not Published
|
Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
Refill Policy: |
Contact program |
Other Information: |
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