CONTACT
INFO |
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Address: |
, |
Phone: |
1-877-447-3243 |
Provider Phone: |
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Fax: |
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Website: |
Program website |
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ELIGIBILITY
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Eligibility
Info: |
Patient must have a relapsing form of MS.
Eligibility determined on case-by-case basis.
Patient must call for a prescreening.
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Couple |
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% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
Not
Published |
US citizenship/residency specified:
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Yes |
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APPLICATION |
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Attachments
Required: |
Financial
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Physician
License #
Required: |
Not Published
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Prescriber
Signature
Allowed: |
Not Published
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Application
may be
faxed: |
No
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Eligibility
determination
letter sent: |
Patient
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MEDICATION |
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Receives: |
Medication
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Shipped To: |
Patient
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Quantity in
Shipment: |
Not Published
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Delivery Time: |
0-1 week
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Re-application
Policy: |
New application every 12 months
New financial information every 12 months
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Refill Policy: |
Program will contact patient to arrange for refills. |
Other Information: |
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