Contact info
- Phone
- 1-877-744-5675
- Fax
- 1-877-736-6506
- Mailing address
- PO Box 220366Charlotte, NC 28222-0366
Eligibility
- Call program for details.
- Patients with Medicare Part D may be eligible.
- Program provides, co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.
- Income limit, single
- 500% of the federal poverty level
- Income limit, couple
- 500% 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
- Front/back of insurance cards, if applicable
- Prescriber license number
- NPI number
- Both DEA and state license numbers
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- Varies
- Shipped to
- Varies
- Supply per shipment
- Varies
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Adcetris (brentuximab vedotin)
- Besponsa (inotuzumab ozogamicin)
- Bosulif (bosutinib)
- Braftovi capsules (encorafenib)
- Daurismo (glasdegib sodium)
- Elrexfio (elranatamab-bcmm)
- Ibrance (palbociclib)
- Inlyta (axitinib)
- Lorbrena (lorlatinib)
- Mektovi tablets (binimetinib)
- Mylotarg