Contact info
- Phone
- 1-844-447-5662
- Fax
- 1-800-645-9043
Eligibility
- Patient must be uninsured, or insurance does not cover the medication.
- Patient must not be receiving prescription drug coverage through a government Program (excluding Medicare), which includes Medicaid, VA, DOD or TriCare benefits.
- Patients with Medicare Part D may be eligible.
- Program also provides co-pay assistance.
- Income limit, single
- 500% of the federal poverty level
- Income limit, couple
- 500% of the federal poverty level
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- 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
- Proof of income
- Prescriber license number
- NPI number
- DEA number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider and patient
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Jemperli (dostarlimab)
- Ojjaara (momelotinib)
- Zejula (niraparib)