Contact info
- Phone
- 1-855-823-7878
- Fax
- 1-877-695-8304
Eligibility
- Eligibility determined on case-by-case basis.
- Patients with Medicare Part D may be eligible, contact program for details.
- Income requirements based on FPL.
- Program offers co-payment assistance, reimbursement support, and patient assistance programs for eligible patients.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- 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
- Attach insurance information if applicable
- Prescriber license number
- NPI number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
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
- Not published
Medications covered
- Ravicti Liquid (glycerol phenylbutyrate)