| CONTACT
INFO |
|
| Address: |
90 East Halsey Rd. Suite 210
Parsippany, NJ 07054 |
| Phone: |
1-866-982-5438 |
Provider Phone: |
|
| Fax: |
|
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must not have prescription coverage for medication needed and cannot be covered by or be eligible for any government prescription coverage such as Medicaid, Veteran's Administration, or any state or local programs.
Patient cannot be enrolled in Medicare Part D.
Program offers co-pay assistance, and patient assistance programs are for eligible patients. |
| Income at or below: |
Single |
|
200
% FPL |
| |
Couple |
|
200
% 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
Prescription
|
Physician
License #
Required: |
DEA
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
No
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
90 days
|
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 3 months
New financial information every 12 months
New prescription every 3 months
|
| Refill Policy: |
A new application with new prescription is needed for refills. |
| Other Information: |
|
|