| CONTACT
INFO |
|
| Address: |
1330 Enclave Parkway Suite 125
Houston, TX, 77077 |
| Phone: |
1-844-599-2273 |
Provider Phone: |
|
| Fax: |
1-855-880-5262 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be uninsured or insured medically but with no prescription coverage.
Patients with certain Medicare Part D plans may be eligible and can apply to determine eligibility.
Online application available on Program Website.
|
| Income at or below: |
Single |
|
500
% FPL |
| |
Couple |
|
500
% FPL |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
No
|
| 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: |
Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
All approved patients will be subject to a reverification of continued eligibility
every 90 days. Continued eligibility beyond the initial 24 months will require
re-enrollment
|
| Refill Policy: |
Not Published
|
| Other Information: |
Copay Assistance is also available. |
|