| Insurance Status |
Must have no prescription coverage |
| Those with Part D Eligible? |
No, must be ineligible |
| Income |
At or below $45,000 if single, $60,000 for family of 2, $75000 for 3, $90,000 for4, $105,000 for 5 |
| Diagnosis/Medical Criteria |
Not specified |
| US Residency Required? |
Not specified |
|
| Obtaining |
Enroll online |
| Receiving |
Downloaded from website |
| Returning |
Mail |
| Doctor's Action |
Not applicable |
| Applicant's Action |
If eligible, respond to 4 questions to enroll |
| Decision Communicated |
Patient notified |
| Decision Timeframe |
Not applicable |
|
| Amount/Supply
| Not applicable |
| Sent To |
Patient sent savings card to be used at pharmacy |
| Delivery Time |
Not applicable |
| Refill Process |
Not applicable |
| Limit |
Not applicable |
| Re-application |
Not applicable |
|
