Contact info
- Phone
- 1-855-463-7989
- Fax
- 1-855-825-0488
Eligibility
- Patient must be uninsured or underinsured.
- Patient must not be eligible for Medicare, Medicaid, or any other government program.
- Must meet program income guidelines which are not disclosed.
- Program offers co-payment assistance, patient 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
- Not published
- 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
- 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
- Varies
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- New application every 12 months
- New proof of income every 12 months
Medications covered
- Xeomin Injection (incobotulinumtoxinA)