An application, to be completed by both the physician and the patient, will be faxed to the physician. Prescriber must sign and date the form and attach an original signed Rx. Patient must answer questions about income, healthcare coverage and Rx coverage, sign and date the form and provide proof of income. Prior to mailing the form, patient must call to review the application with a program administrator. If the patient has a cap on their prescription coverage, or the medication requested is not on formulary, a letter from the insurance company must be attached stating so. The form will be faxed to the physician who must sign and date the form and attach an original prescription.
Patient eligibility is reviewed on a yearly basis.