| Insurance Status |
Must have no prescription coverage |
| Those with Part D Eligible? |
No |
| Income |
Not disclosed |
| Diagnosis/Medical Criteria |
Not specified |
| US Residency Required? |
Yes |
|
| Obtaining |
Call or download |
| Receiving |
Faxed or mailed |
| Returning |
Mail or fax |
| Doctor's Action |
Hospital contact must complete application and attach dispensing record |
| Applicant's Action |
Complete section, sign |
| Decision Communicated |
Hospital notified of acceptance or denial |
| Decision Timeframe |
Within 48 hours |
|
| Amount/Supply
| Not specified |
| Sent To |
Doctor's office or specific site |
| Delivery Time |
Not specified |
| Refill Process |
Not specified |
| Limit |
Not specified |
| Re-application |
Not specified |
|