CONTACT
INFO |
|
Address: |
D-617927, AP5 NE 1 N. Waukegan Rd.
North Chicago, IL 60064 |
Phone: |
1-800-222-6885 |
Provider Phone: |
|
Fax: |
1-866-250-2803 |
Website: |
Program Website |
|
ELIGIBILITY
|
|
Eligibility
Info: |
Patient must not have health insurance OR limited insurance coverage (including Medicare) for an AbbVie medicine and meet financial criteria based on household income and out-of-pocket medical expenses. |
Income at or below: |
Single |
|
600
% FPL |
|
Couple |
|
600
% 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
Copy of insurance cards, if applicable
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Patient
|
Quantity in
Shipment: |
Not Published
|
Delivery Time: |
Not Published
|
Re-application
Policy: |
Not Published |
Refill Policy: |
Program will contact patient or provider to schedule next delivery. |
Other Information: |
|
|