| Insurance Status |
Must be uninsured |
| Those with Part D Eligible? |
No |
| Income |
At or below $19,600 for an individual, $26,400 for a family |
| Diagnosis/Medical Criteria |
Not required |
| US Residency Required? |
No residency requirements |
|
| Obtaining |
Doctor/Doctor's office must call |
| Receiving |
Faxed |
| Returning |
Mail or fax |
| Doctor's Action |
Complete section, sign, attach prescription and include copy of DEA or state license number |
| Applicant's Action |
Complete section, sign |
| Decision Communicated |
Doctor notified |
| Decision Timeframe |
Not specified |
|
| Amount/Supply
| Up to 30 day supply |
| Sent To |
Doctor's office |
| Delivery Time |
Within 4-6 weeks |
| Refill Process |
New application and new prescription |
| Limit |
Not applicable |
| Re-application |
New application needed for each refill |
|
