Contact info
- Phone
- 1-800-830-9159
- Fax
- 1-800-497-0928
- Mailing address
- P.O. Box 5727Louisville, KY 40255-0727
Eligibility
- Patient must not have health coverage, does not have enough coverage to obtain the medication or does not have access to alternate sources of coverage or funding.
- Income limit, single
- 500% of the federal poverty level
- Income limit, couple
- 500% of the federal poverty level
- Medical expenses can be deducted
- No
- 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
- NJ & NY physician's must include a prescription
- Prescriber license number
- State license 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
- Supply per shipment
- 90-day supply
- 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
- Carbatrol (carbamazepine)
- Dexilant (dexlansoprazole)
- Eohilia (budesonide oral suspension)
- Fosrenol (lanthanum carbonate)
- Intuniv Extended Release Tablets (guanfacine)
- Lialda (mesalamine)
- Pentasa (mesalamine)
- Prevacid SoluTab (lansoprazole)
- Rozerem (ramelteon)
- Trintellix (vortioxetine)