| CONTACT
INFO |
|
| Address: |
PO Box 270
Somerville, NJ 08876 |
| Phone: |
1-800-222-6885 |
Provider Phone: |
|
| Fax: |
1-866-898-1473 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be diagnosed with a seizure disorder or be a currently enrolled patient seeking re-enrollment.
Patient must be being treated by a licensed U.S. health care provider on an outpatient basis.
Patient must have no health insurance or limited insurance coverage (including Medicare) for an AbbVie medicine and meet financial criteria based on household income and out-of-pocket medical expenses. |
| Income at or below: |
Single |
|
600
% FPL |
| |
Couple |
|
600
% 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: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Patient, unless otherwise noted
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Call program for refills |
| Other Information: |
|
|