| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-833-742-0791 |
Provider Phone: |
|
| Fax: |
1-833-512-0497 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be uninsured or have inadequate coverage through commercial, employer group, or government insurance coverage.
Patients with Medicare Part D must spend 4% of gross annual household income on out-of-pocket prescription costs for yourself and/or other household members.
|
| |
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: |
Both DEA and State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Either Provider and Patient
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
Not Published
|
| Other Information: |
|
|