| CONTACT
INFO |
|
| Address: |
50 Whittemore Street
Gloucester, MA 01930 |
| Phone: |
1-866-562-7902 |
Provider Phone: |
|
| Fax: |
1-888-246-6527 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must not have Health insurance coverage (private or government) that pays for requested products 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 |
|
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: |
Prescription
|
Physician
License #
Required: |
Both DEA and State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Not Published
|
Eligibility
determination
letter sent: |
Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Either Provider and Patient
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
0-1 week
|
| Re-application
Policy: |
New application every 6 months
New prescription every 3 months
|
| Refill Policy: |
Physician's office contacts the program |
| Other Information: |
|
|