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Program Details

Mylan EpiPen 2-Pak Auto-Injector Patient Assistance Program

EpiPen (epinephrine)
Address: 781 Chestnut Ridge Road
Morgantown, WV 26505
Phone: 1-800-796-9526 Provider Phone:
Fax: 1-877-427-7290 Website: Program Website
Eligibility Info:
  • The patient must not have prescription insurance coverage through Medicaid, Medicare Part D, TriCare, a qualified health plan purchased on a state-based, partnership, or federally-facilitated Exchange, or any other public or private program or insurer.
  • The patient has commercial prescription drug coverage only for generic products and the patient must not have prescription insurance coverage through any state or federally funded program including, without limitation, to Medicare, Medicaid, TriCare, or Medicare Part D.
  • Income at or below: Single 400 % FPL
      Couple 400 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    Attachments Required: Financial
    Physician License #
    Both DEA and State
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Both Provider and Patient
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment:
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Once approved, patient is eligible replacement medication for up to one year. A completed Replenishment Authorization Form must be faxed and approved.
    Other Information:

    Last Updated: 11/28/2018




    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.

    DocumentForm (English)


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