Contact info
- Phone
- 1-833-965-1620
- Fax
- 1-833-965-1621
Eligibility
- Patient must be uninsured (no insurance) or underinsured (insurance does not cover medication).
- Patient must meet financial requirements to qualify for Medicaid or have Medicaid coverage where the product is not covered
- Patients with Medicare Part D and are not eligible.
- 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
- Proof of income
- Prescription
- 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
- 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
- Santyl (collagenase ointment)