CONTACT
INFO |
|
Address: |
PO Box 222173
Charlotte, NC 28222-2173 |
Phone: |
1-877-423-6597 |
Provider Phone: |
|
Fax: |
1-877-850-9901 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient must not have any insurance and must not be eligible for any state or federal programs.
Patient's with Medicare Part D should contact the program for details.
Patient's with insurance may qualify for the Co-Pay Assistance Program. To enroll, use the enrollment form to the right and check the box for Co-pay Assistance. |
|
Couple |
|
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
No |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
Both DEA and 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: |
Varies |
Delivery Time: |
0-1 week
|
Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
Refill Policy: |
Program contact's physician's office. |
Other Information: |
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