| Insurance Status |
Must have no prescription coverage for needed medication |
| Those with Part D Eligible? |
No |
| Income |
At or below 200% of FPL, adjusted for household size |
| Diagnosis/Medical Criteria |
Not specified |
| 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 |
Doctor notified of denial |
| Decision Timeframe |
2-4 business days |
|
| Amount/Supply
| Up to 6 months supply |
| Sent To |
Doctor's office |
| Delivery Time |
Not specified |
| Refill Process |
Copy of application with new doctor signature |
| Limit |
Not specified |
| Re-application |
New application every 12 months |
|
