Enrollment in the program requires a valid Social Security Number. Physician must indicate condition for which drug is to be prescribed and certify that drug will be used for indicated use only. Physician must agree to follow patient through therapy. If all information needed is obtained over the phone, approval or denial is given immediately. If patient is approved, an application is generated and sent to the physician's office for signatures.
Eligibility is based on patient's insurance status and income level.
Patient must be a U.S. citizen ineligible for prescription assistance through Medicaid or private insurance. Patient must meet established financial criteria. Application form, prescription, and patient's income documentation are required. Maximum of three months supply may be provided per request. Complete financial re-application is required annually.