Contact info
- Phone
- 1-833-613-2419
- Fax
- 1-800-311-0260
Eligibility
- Eligibility is determined on case-by-case basis.
- Patients with Medicare Part D are not eligible.
- Income limit, single
- 600% of the federal poverty level
- Income limit, couple
- 600% of the federal poverty level
- 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
- Proof of income
- Prescriber license number
- NPI number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider
Getting the medication
- Patient receives
- Not published
- Shipped to
- Provider
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- AlloDerm (wound matrix)
- Keller Funnel 2 (surgical device)
- Natrelle (breast implant)
- REVOLVE System (Advanced Adipose System)
- Strattice (reconstructive tissue matrix)
- Strattice BPS (reconstructive tissue matrix)