Contact info
- Phone
- 1-866-728-4368
- Fax
- 1-855-474-3063
- Mailing address
- PO Box 220590Charlotte, NC 28222-0590
Eligibility
- Patient must be uninsured.
- Patients with Medicare are not eligible.
- For patient living in Puerto Rico - must not be eligible for Puerto Rico's Government Health Plan Mi Salud or have applied and been denied.
- Income limit, single
- 300% of the federal poverty level
- Income limit, couple
- 300% 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
- Not published
- Prescriber license number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
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
- Arexvy (Respiratory Syncytial Virus Vaccine, Adjuvanted)
- Boostrix (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine)
- Engerix-B (hepatitis B vaccine (recombinant))
- Shingrix (Zoster Vaccine Recombinant, Adjuvanted)