| CONTACT
INFO |
|
| Address: |
PO Box 220285
Charlotte, NC 28222-0285 |
| Phone: |
1-877-850-0819 |
Provider Phone: |
|
| Fax: |
1-877-850-0821 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must not have prescription coverage, including Medicare and Medicaid.
|
| 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: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
Prescription
|
Physician
License #
Required: |
Both DEA and State
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
Pharmacy
|
| Quantity in
Shipment: |
Up to 90-day supply |
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
Physician's office must contact company |
| Other Information: |
|
|