Contact info
- Phone
- 1-877-785-8906
- Fax
- 1-855-880-5262
Eligibility
- Patient must be uninsured or insured medically but with no prescription coverage.
- Patients with certain Medicare Part D plans may be eligible and can apply to determine eligibility.
- Online application available on Program Website.
- 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
- Prescriber license number
- NPI number
- Both DEA and state license numbers
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Patient
Getting the medication
- Patient receives
- Medication
- Shipped to
- Patient
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- All approved patients will be subject to a reverification of continued eligibility every 90 days. Continued eligibility beyond the initial 24 months will require re-enrollment
More from the program
- Copay Assistance is also available.
Medications covered
- Bimzelx (bimekizumab-bkzx)
- Briviact (brivaracetam)
- CIMZIA (certolizumab pegol)
- Nayzilam (midazolam)
- Neupro Transdermal System (rotigotine)