Contact info
- Phone
- 1-866-696-3873
- Fax
- 1-866-696-7579
- Mailing address
- P.O. Box 5490Louisville, KY, KY 40255
Eligibility
- Contact program for details.
- Must meet program income guidelines, which are not disclosed.
- Program also provides co-pay assistance.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- Yes
- US citizenship or residency required
- Yes
Not sure where your income falls? See this year's federal poverty guidelines (opens in a new tab).
Application process
- Documents to attach
- Not published
- Prescriber license number
- NPI number
- Both DEA and state license numbers
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- Varies
- Shipped to
- Not published
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Valtoco (diazepam nasal spray)