| CONTACT
INFO |
|
| Address: |
PO Box 220590
Charlotte, NC 28222-0590 |
| Phone: |
1-866-728-4368 |
Provider Phone: |
|
| Fax: |
1-855-474-3063 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
The patient must live in one of the 50 states, District of Columbia or Puerto Rico
Patient must be uninsured.
Patients with Medicare Part D Prescription Drug Plan may be eligible. Patient must have spent at least $600 on prescription medicines through Medicare Part D Prescription Drug Plan during this calendar year. |
| Income at or below: |
Single |
|
300
% FPL |
| |
Couple |
|
300
% 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
Copy of Medicare Part D prescription drug card, if applicable.
|
Physician
License #
Required: |
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Either Provider and Patient
|
| Quantity in
Shipment: |
Up to 90-day supply |
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
New application every 12 months
|
| Refill Policy: |
Patient must contact program |
| Other Information: |
Note: Puerto Rico Residents do not qualify for vaccine products. |
|