| Insurance Status |
Must have no prescription coverage or been denied coverage |
| Those with Part D Eligible? |
No |
| Income |
Gross annual household income at or below $100,000 |
| Diagnosis/Medical Criteria |
Not disclosed |
| US Residency Required? |
Must be treated by US licensed healthcare provider |
|
| Obtaining |
Doctor/Doctors office starts process by filling out enrollment/statement of medical necessity forms |
| Receiving |
Faxed, mailed or downloaded from website |
| Returning |
Mail or fax |
| Doctor's Action |
Complete and sign the application and attach a letter of medical necessity |
| Applicant's Action |
Complete Patient Authorization and Notice of Information Form available on website, attach proof of income |
| Decision Communicated |
Doctor notified |
| Decision Timeframe |
Not specified |
|
| Amount/Supply
| Varies |
| Sent To |
Doctor's office, hospital, or pharmacy |
| Delivery Time |
Not specified |
| Refill Process |
Not specified |
| Limit |
Not specified |
| Re-application |
New application yearly |
|
