Contact info
- Phone
- 1-866-398-0833
Eligibility
- Eligibility determined on case-by-case basis. Contact program for details.
- 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
- Not published
- Prescriber license number
- Not published
- Who can sign
- Physician
- Application can be faxed
- Not published
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- Not published
- Shipped to
- Not published
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Apokyn injection 10mg/mL (apomorphine hydrochloride)
- Gocovri (amantadine; extended release capsule)
- Myobloc Injection (rimabotulinumtoxinB)
- Oxtellar XR Tablet (oxcarbazepine)
- Qelbree capsule (viloxazine)
- Trokendi XR Capsule (topiramate)
- Xadago tablet (safinamide tablet)