| Insurance Status |
Must have no prescription insurance, be ineligible for any state and federal programs |
| Those with Part D Eligible? |
No |
| Income |
At or below 200% of FPL |
| Diagnosis/Medical Criteria |
Medically appropriate condition |
| US Residency Required? |
Yes, and must be treated by US doctor |
|
| Obtaining |
Call or download |
| Receiving |
Faxed, mailed or downloaded from website |
| Returning |
Mail, fax or email |
| Doctor's Action |
Complete section, sign, attach prescription |
| Applicant's Action |
Complete section, sign, attach proof of income |
| Decision Communicated |
Patient notified in writing |
| Decision Timeframe |
2-4 business days |
|
| Amount/Supply
| Up to 30 day supply |
| Sent To |
Doctor's office or patient's home |
| Delivery Time |
Within 5-7 business days |
| Refill Process |
Patient must contact company |
| Limit |
One year |
| Re-application |
Must re-enroll at end of calendar year |
|
