| Insurance Status |
Must not have public insurance, may have private insurance |
| Those with Part D Eligible? |
No |
| Income |
Not disclosed |
| Diagnosis/Medical Criteria |
Not specified |
| US Residency Required? |
MA residents are not eligible |
|
| Obtaining |
Call for prescreening |
| Receiving |
Sent to Doctor's office |
| Returning |
Mail or fax |
| Doctor's Action |
Complete section, sign, attach prescription |
| Applicant's Action |
Complete section, sign |
| Decision Communicated |
Patient and Doctor are notified |
| Decision Timeframe |
Within 24-48 hours |
|
| Amount/Supply
| Varies |
| Sent To |
Patient sent card to be used at pharmacy |
| Delivery Time |
ID number given over the phone or card shipped within 7-10 business days |
| Refill Process |
Patient presents voucher/card to pharmacy for each refill |
| Limit |
Not specified |
| Re-application |
Must re-enroll at end of calendar year |
|