| CONTACT
INFO |
|
| Address: |
Attn: Truax
, |
| Phone: |
1-800-930-5727 |
Provider Phone: |
|
| Fax: |
|
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Program offers co-pay card and savings to those with commercial insurance and cash paying uninsured patients.
Patients with Medicare Par D may be eligible.
|
| |
Couple |
|
% 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:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Not Published
|
Physician
License #
Required: |
|
Prescriber
Signature
Allowed: |
|
Application
may be
faxed: |
Not Published
|
Eligibility
determination
letter sent: |
|
|
| MEDICATION |
|
| Receives: |
Pharmacy Card
|
| Shipped To: |
Download from website - click Proram Website above
|
| Quantity in
Shipment: |
Up to 3-month supply |
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|