| Insurance Status |
Must have insurance |
| Those with Part D Eligible? |
Yes |
| Income |
At or below 500% of FPL |
| Diagnosis/Medical Criteria |
Medically appropriate condition |
| US Residency Required? |
Must reside and receive treatment in US |
|
| Obtaining |
Call or complete online |
| Receiving |
Sent out or may be completed online |
| Returning |
Fax, mail or submit online |
| Doctor's Action |
Will be discussed with patient and Doctor after request is received |
| Applicant's Action |
Complete section, sign, attach proof of income |
| Decision Communicated |
Patient and Doctor notified in writing |
| Decision Timeframe |
Within 48 hours |
|
| Amount/Supply
| Not applicable |
| Sent To |
Patient sent card to be used at pharmacy |
| Delivery Time |
Once approved ; shipped same day. |
| Refill Process |
Patient presents voucher/card to pharmacy for each refill |
| Limit |
None |
| Re-application |
New application every 12 months |
|
