Contact info
- Phone
- 1-833-274-8684
- Mailing address
- PO Box 2355Morristown, NJ 07962
Eligibility
- Contact program for details.
- Patient must be a permanent US resident
- Income guidelines are based on fixed annual gross household income per household size. See guidelines below.
- Income limit, single
- $100,000 a year
- Income limit, couple
- $150,000 a year
- Other income rules
- $25k for each additional household member
- Medical expenses can be deducted
- No
- 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
- Patient consent form
- 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
- Pharmacy card
- Shipped to
- Provider
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- BRIUMVI (ublituximab-xiiy)