| Insurance Status |
Must have no prescription coverage |
| Those with Part D Eligible? |
No, must be ineligible |
| Income |
Based on FPL |
| Diagnosis/Medical Criteria |
Not specified |
| US Residency Required? |
Puerto Rico & US Virgin Island residents are not eligible |
|
| Obtaining |
Call or download |
| Receiving |
Faxed |
| Returning |
Mail or fax |
| Doctor's Action |
Complete section, sign |
| Applicant's Action |
Complete section, sign, attach proof of income |
| Decision Communicated |
Doctor notified |
| Decision Timeframe |
Not specified |
|
| Amount/Supply
| Up to 120 day supply |
| Sent To |
Doctor's office |
| Delivery Time |
Within 4 weeks |
| Refill Process |
Refill/reorder form included with shipment |
| Limit |
Not specified |
| Re-application |
New application, new documentation yearly |
|
