CONTACT
INFO |
|
Address: |
, |
Phone: |
1-866-435-5677 |
Provider Phone: |
|
Fax: |
1-888-525-2416 |
Website: |
Program Website |
|
ELIGIBILITY
|
|
Eligibility
Info: |
Patients must not have prescription coverage for medication needed.
Patients with Medicare Part D are not eligible.
Patient must meet program income guidelines, which are not disclosed. |
|
Couple |
|
% 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:
|
Not
Published |
|
APPLICATION |
|
Attachments
Required: |
Not Published
|
Physician
License #
Required: |
Both DEA and State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Patient
|
Quantity in
Shipment: |
Not Published
|
Delivery Time: |
Not Published
|
Re-application
Policy: |
Not Published |
Refill Policy: |
Not Published
|
Other Information: |
Program provides several services, including:
Co-pay assistance to eligible patients.
Free medication to eligible patients through the Patient Assistance Program.
Help navigating insurance coverage process and coordinate delivery from specialty pharmacy. |
|