| Insurance Status |
Must have no prescription coverage for needed medication |
| Those with Part D Eligible? |
Yes, if in the donut hole |
| Income |
At or below 350% of FPL |
| Diagnosis/Medical Criteria |
Not required |
| US Residency Required? |
Yes |
|
| Obtaining |
Call |
| Receiving |
Faxed |
| Returning |
Mail or fax |
| Doctor's Action |
Complete section, sign, attach prescription |
| Applicant's Action |
Complete section, sign, attach proof of income and any insurance information |
| Decision Communicated |
If denied, patient and Doctor notified |
| Decision Timeframe |
Not specified |
|
| Amount/Supply
| Not specified |
| Sent To |
Doctor's office or patient's home |
| Delivery Time |
Within 2 weeks |
| Refill Process |
Copy of application with new dates, signature and new prescription |
| Limit |
Not specified |
| Re-application |
New application yearly |
|
