Contact info
- Phone
- 1-833-773-8446
- Fax
- 1-855-237-0134
- Mailing address
- PO Box 1587Jeffersonville, IN 47131
Eligibility
- Patient must be uninsured or underinsured.
- Patient must be 12 years of age or older and have a valid prescription.
- Patients with Medicare Part D may be eligible if the patient has applied for and been denied the LIS and meets the further program conditions.
- Income limit, single
- 250% of the federal poverty level
- Income limit, couple
- 250% of the federal poverty level
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- US citizenship or residency required
- Not published
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
- Medicaid denial letter
- Prescriber license number
- NPI number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider or 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
- Spevigo (spesolimab-sbzo)