| CONTACT
INFO |
|
| Address: |
PO Box 220578
Charlotte, NC 28222-0578 |
| Phone: |
1-855-395-3248 |
Provider Phone: |
|
| Fax: |
1-888-335-3264 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be uninsured or underinsured.
Patients with Medicare Part D are not eligible. |
| Income at or below: |
Single |
|
% FPL |
| |
Couple |
|
% FPL |
| Income at or below: |
Not
Published |
| Other Income
Requirements: |
Gross annual household income at or below $100,000 |
| 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
|
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: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
Not Published
|
| Other Information: |
Co-pay and reimbursement assistance is also available. |
|