| CONTACT
INFO |
|
| Address: |
1120 Win Drive
Bethlehem, PA 18017-7059 |
| Phone: |
1-877-882-5950 |
Provider Phone: |
|
| Fax: |
1-877-885-1103 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Determined on case-by-case basis.
Physicians must apply for this program on behalf of their patients.
Patients with Medicare Part D are not eligible.
This program also provides copay assistance and has a Nutritional Rebate Program. |
| |
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: |
None
|
Physician
License #
Required: |
DEA
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Provider
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
Up to 3-month supply |
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 3 months
|
| Refill Policy: |
3 refills
|
| Other Information: |
|
|