| Insurance Status |
Must have no prescription coverage for needed medication |
| Those with Part D Eligible? |
Considered on exception basis |
| Income |
Based on FPL |
| Diagnosis/Medical Criteria |
Not required |
| US Residency Required? |
Must reside in the US |
|
| Obtaining |
Call or download |
| Receiving |
Faxed, mailed or downloaded from website |
| Returning |
Mail or fax |
| Doctor's Action |
Complete section, sign |
| Applicant's Action |
Complete section, sign and provide annual income information. Proof of income may be request by program at any time |
| Decision Communicated |
Patient and Doctor are notified |
| Decision Timeframe |
5-7 business days |
|
| Amount/Supply
| Up to 90 day supply |
| Sent To |
Doctor's office |
| Delivery Time |
Within 7-10 business days |
| Refill Process |
Patient or Doctor must contact company |
| Limit |
Not specified |
| Re-application |
New application yearly |
|