CONTACT
INFO |
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Address: |
50 Whittemore Street
Gloucester, MA 01930 |
Phone: |
1-866-562-7902 |
Provider Phone: |
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Fax: |
1-888-246-6527 |
Website: |
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ELIGIBILITY
|
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Eligibility
Info: |
Patient must not have Health insurance coverage (private or government) that pays for requested medication and haven't for at least 3 months.
Patients with Medicare Part D may be eligible on a case-by-case basis. Copy of insurance denial letter required. |
Income at or below: |
Single |
|
100
% FPL |
|
Couple |
|
100
% 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:
|
Yes |
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APPLICATION |
|
Attachments
Required: |
Prescription
|
Physician
License #
Required: |
DEA
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Either Provider and Patient
|
Quantity in
Shipment: |
30 days
|
Delivery Time: |
0-1 week
|
Re-application
Policy: |
New application every 6 months
|
Refill Policy: |
Physician's office must contact program |
Other Information: |
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