Contact info
- Phone
- 1-866-728-4368
- Fax
- 1-855-474-3063
- Mailing address
- PO Box 220590Charlotte, NC 28222-0590
Eligibility
- The patient must live in one of the 50 states, District of Columbia or Puerto Rico
- Patient must be uninsured.
- Patients with Medicare Part D Prescription Drug Plan may be eligible. Patient must have spent at least $600 on prescription medicines through Medicare Part D Prescription Drug Plan during this calendar year.
- NOTE for Blujepa: The patient will need a signed prescription to take to the retail pharmacy. Download the drug-specific application form.
- Income limit, single
- 300% of the federal poverty level
- Income limit, couple
- 300% 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
- Proof of income
- Prescription
- Copy of Medicare Part D prescription drug card, if applicable.
- Prescriber license number
- Not published
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Patient
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider or patient
- Supply per shipment
- Up to 90-day supply
- Time to first delivery
- Not published
- Refills
- Patient must contact program
- Staying enrolled
- New application every 12 months
More from the program
- Note: Puerto Rico Residents do not qualify for vaccine products.
Medications covered
- Anoro Ellipta (umeclidinium and vilanterol inhalation powder)
- Arnuity Ellipta (fluticasone furoate inhalation powder)
- Blenrep (belantamab mafodotin)
- Blujepa (gepotidacin)
- Breo Ellipta (fluticasone furoate and vilanterol inhalation powder)
- Incruse Ellipta (umeclidinium inhalation powder)
- Jemperli (dostarlimab)
- Lamictal (lamotrigine)
- Lamictal ODT (patient titration kits) (lamotrigine)
- Lamictal Starter Kits (lamotrigine)