Contact info
- Phone
- 1-855-718-4362
- Fax
- 1-833-390-1379
- Mailing address
- 270 Cramer Creek CourtDublin, OH 43017
Eligibility
- Patient must be uninsured.
- Patients with Medicare Part D may apply if Part D does not allow or pay for any part of medication. Patients in the donut hole do not qualify.
- Program also provides co-pay assistance.
- Income limit, single
- 400% of the federal poverty level
- Income limit, couple
- 400% 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 and patient
Getting the medication
- Patient receives
- Medication
- Shipped to
- Patient
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- New application every 12 months
- New proof of income every 12 months
Medications covered
- Sevenfact (coagulation factor VIIa (recombinant)-jnew)