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. |
|