Contact info
- Phone
- 1-888-847-4877
- Fax
- 1-888-847-1797
- Mailing address
- PO Box 222138Charlotte, NC 28222-2138
Eligibility
- Patient must have no insurance coverage or access to the prescribed product or treatment via their insurance.
- Patients with Medicare Part D may 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
- Proof of income
- Medicaid denial letter
- Prescriber license number
- NPI 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
- Not published
- Time to first delivery
- 0–2 weeks
- Refills
- A refill form must be faxed to program.
- Staying enrolled
- New application every 12 months
- New proof of income every 12 months
Medications covered
- Adacel (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine)
- Admelog (insulin lispro injection)
- Apidra (insulin glulisine)
- Elitek (rasburicase)
- Imovax (rabies vaccine)
- Jevtana (cabazitaxel)
- Lantus (insulin glargine)
- Lantus (SoloStar pen) (insulin glargine)
- Lovenox (enoxaparin sodium)
- MenQuadfi (meningococcal)