CONTACT
INFO |
|
Address: |
PO Box 13185
La Jolla, CA 92039 |
Phone: |
1-800-477-6472 |
Provider Phone: |
|
Fax: |
1-866-317-6235 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient is uninsured, has no prescription drug coverage, or has insurance that specifically excludes CRESEMBA.
Patients with Medicare Part D may be eligible, contact program for details.
Program also offers co-pay assistance.
|
|
Couple |
|
% FPL |
Income at or below: |
Not
Published |
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
Prescription
|
Physician
License #
Required: |
Not Published
|
Prescriber
Signature
Allowed: |
Not Published
|
Application
may be
faxed: |
Not Published
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Patient
|
Quantity in
Shipment: |
Up to 28 day supply |
Delivery Time: |
0-1 week
|
Re-application
Policy: |
Not Published |
Refill Policy: |
Patient must contact program for refills |
Other Information: |
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