Contact info
- Phone
- 1-800-727-5400
- Mailing address
- PO Box 1206Wilkes Barre, PA 18703-1206
Eligibility
- Patients must not have insurance or other coverage for your prescription medicine, including private insurance, Medicare, Medicaid, HMOs, state pharmacy assistance programs, Veterans' assistance programs, or any other social service agencies.
- If you do not meet the income or prescription drug coverage criteria, your income is below a set upper limit, and there are special circumstances of financial and medical hardship that apply to your situation, you can request that an exception be made for you.
- Medicare Part D patients might be eligible, contact program for details.
- Income limit, single
- 400% of the federal poverty level
- Income limit, couple
- 400% of the federal poverty level
- Medical expenses can be deducted
- Not published
- 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
- None
- Prescriber license number
- State license number
- Who can sign
- Physician
- Physician assistant
- Application can be faxed
- No
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider or patient
- Supply per shipment
- 90-day supply
- Time to first delivery
- 0–2 weeks
- Refills
- 3 refills
- Patient must contact program for refills
- Staying enrolled
- New application every 12 months
Medications covered
- Belsomra (suvorexant)
- Delstrigo (doravirine, lamivudine, and tenofovir disoproxil fumarate)
- Dificid (fidaxomicin)
- EMEND (aprepitant)
- Isentress (raltegravir)
- Isentress HD tablet (raltegravir)
- Janumet (sitagliptin/metformin HCL)
- Janumet XR (sitagliptin/metformia HCI extended -release)
- Januvia (sitagliptin phosphate)
- Lagevrio (molnupiravir)