| CONTACT
INFO |
|
| Address: |
Attn: Enrollment 2611 Internet Blvd., Suite 105
Frisco, TX 75034 |
| Phone: |
1-877-968-7233 |
Provider Phone: |
|
| Fax: |
1-214-570-3621 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Call for most recent medications list as is subject to change based on available funding.
Patients must have valid medical insurance coverage. Patients who are applying for copayment assistance must have at least 50% insurance coverage or more to be eligible for copayment assistance, excluding deductibles.
Patients must have been prescribed a medication that is part of the Good Days formulary.
Patients must meet our annual household income criteria. |
| |
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:
|
Not
Published |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
Not Required
|
Prescriber
Signature
Allowed: |
Not Published
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Not Published
|
| Shipped To: |
Not Published
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Must reapply at the end of the calendar year.
|
| Refill Policy: |
Not Published
|
| Other Information: |
|
|