| CONTACT
INFO |
|
| Address: |
PO Box 222138
Charlotte, NC 28222-2138 |
| Phone: |
1-800-982-8292 |
Provider Phone: |
|
| Fax: |
1-888-847-1797 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must not have insurance coverage or not have access to the prescribed product or treatment via their insurance.
Patient must have Osteoarthritis of the knee.
Patient must be under the care of a licensed healthcare provider who is authorized to
prescribe, dispense, and administer medicine in the US.
|
| Income at or below: |
Single |
|
400
% FPL |
| |
Couple |
|
400
% 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: |
DEA
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: |
Not Published
|
| Delivery Time: |
2-4 weeks
|
| Re-application
Policy: |
|
| Refill Policy: |
|
| Other Information: |
|
|