CONTACT
INFO |
|
Address: |
2250 Perimeter Park Drive Suite 300
Morrisville, NC , NC 27560 |
Phone: |
1-888-392-6674 |
Provider Phone: |
|
Fax: |
1-844-633-8444 |
Website: |
Program Website |
|
ELIGIBILITY
|
|
Eligibility
Info: |
Patient must not have insurance, was denied coverage or is awaiting public assistance benefits determination.
Patients enrolled in Medicare Part D are not eligible.
Program also provides co-pay assistance. |
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: |
Not
Published |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
DEA
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Varies
|
Shipped To: |
Patient
|
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: |
|
Other Information: |
|
|