| Insurance Status |
May have insurance |
| Those with Part D Eligible? |
Yes |
| Income |
At or below 200% of FPL |
| Diagnosis/Medical Criteria |
Not specified |
| US Residency Required? |
Must be treated by US Doctor |
|
| Obtaining |
Call or download |
| Receiving |
Faxed, mailed or downloaded from website |
| Returning |
Mail or fax |
| Doctor's Action |
Complete section, sign |
| Applicant's Action |
Complete, sign, attach proof of income |
| Decision Communicated |
Patient notified of denial in writing |
| Decision Timeframe |
Within 24-48 hours |
|
| Amount/Supply
| Up to 6 months supply |
| Sent To |
Doctor's office |
| Delivery Time |
Within 3 weeks of receiving application |
| Refill Process |
Copy of application with new dates |
| Limit |
Not specified |
| Re-application |
New application yearly |
|