Contact info
- Phone
- 1-877-237-4881
- Fax
- 1-877-438-4404
- Mailing address
- PO Box 501827San Diego, CA 92150
Eligibility
- Patients may be eligible who reside in the United States, meet insurance and income requirements, and have a valid prescription for medication needed.
- Call for current medication list as is subject to change.
- 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
- Proof of income
- Prescriber license number
- NPI 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 or patient
- Supply per shipment
- Varies by medication
- Time to first delivery
- 0–2 weeks
- Refills
- Reorder form must be sumbitted
- Staying enrolled
- New application every 12 months
- New proof of income every 12 months
Medications covered
- Ajovy (fremanezumab-vfrm)
- Austedo (deutetrabenazine)
- Austedo XR (deutetrabenazine)
- Proglycem oral suspension (diazoxide)
- Uzedy (risperidone extended-release injectable suspension)