| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-844-414-6756 |
Provider Phone: |
|
| Fax: |
1-844-660-7083 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be a U.S. citizen or legal resident.
Patient must not have insurance or are underinsured.
Patient must be prescribed Rayaldee for FDA-approved diagnosis.
Program offers co-pay assistance, patient support, and patient assistance programs for eligible patients. |
| |
Couple |
|
% FPL |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
Not Required
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Must re-enroll at end of calendar year.
|
| Refill Policy: |
Not Published
|
| Other Information: |
The Rayaldee Service Request Form (SRF) must be submitted before submitting the Rayaldee Patient Assistance Program Application.
|
|