| CONTACT
INFO |
|
| Address: |
50 Whittemore Street
Gloucester, MA , MA 01930 |
| Phone: |
1-888-236-4167 |
Provider Phone: |
|
| Fax: |
1-888-246-6527 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must not have prescription coverage for needed medication.
Patients with Medicare Part D are eligible if medication is not covered. |
| 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: |
Yes |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
Prescription
Copy of valid drivers license or state photo ID
|
Physician
License #
Required: |
DEA
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Patient and/or Doctor notified
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
|
| Quantity in
Shipment: |
30 days
|
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 6 months
|
| Refill Policy: |
Patient contacts program for refills |
| Other Information: |
|
|