Contact info
- Phone
- 1-800-848-4876
- Fax
- 1-877-329-8484
Eligibility
- Patient must not have prescription coverage for medication needed.
- Patient must meet program income criteria which is based on Federal Poverty Level.
- Program offers co-payment assistance, reimbursement support, patient support, and patient assistance programs for eligible patients.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- 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
- NPI number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- 1 Dose
- Shipped to
- Provider
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Vivitrol (naltrexone for extended-release injectable suspension)