| Insurance Status |
Must have no prescription coverage for needed medication |
| Those with Part D Eligible? |
No |
| Income |
At or below 200% of FPL |
| Diagnosis/Medical Criteria |
Not required |
| US Residency Required? |
Yes |
|
| Obtaining |
Call |
| Receiving |
Faxed or mailed |
| Returning |
Mail or fax |
| Doctor's Action |
Complete section, sign |
| Applicant's Action |
Complete section, sign, attach proof of income |
| Decision Communicated |
Not specified |
| Decision Timeframe |
Within 2-3 days |
|
| Amount/Supply
| Varies |
| Sent To |
Doctor's office |
| Delivery Time |
Within 2 business days |
| Refill Process |
Copy of application with new signatures and new prescription |
| Limit |
Not specified |
| Re-application |
Company contacts patient about reapplying |
|
