rxhelp360.org
| Drug Information | ||||||||||||||||||||||
| Drug | Benzagel | |||||||||||||||||||||
| Generic Equivalent | benzoyl peroxide | |||||||||||||||||||||
| Topic | Skin | |||||||||||||||||||||
| Program Contact Info / Application Submission | ||||||||||||||||||||||
| Program | Dermik Patient Assistance Program | |||||||||||||||||||||
| Company | Dermik | |||||||||||||||||||||
| Form | Download PDF | |||||||||||||||||||||
| Address | PO Box 65Somerville, NJ 08876 | |||||||||||||||||||||
| Phone | 1-866-268-7326 | |||||||||||||||||||||
| Fax | 866-910-9024 | |||||||||||||||||||||
| Program Details | ||||||||||||||||||||||
| Details | Up to a 90-day supply is sent to the doctor's office. A copy of the application with new dates, new signatures and a new prescription is needed for refills. Once a year a new application with financial documentation is needed. | |||||||||||||||||||||
| Program Requirements | ||||||||||||||||||||||
| Information | The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number. The patient must fill out a section, sign the application and attach proof of income. | |||||||||||||||||||||
| Details | Insurance card will be considered on a case by case basis Drivers license required Proof of Income NOT required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero incomeNOT required as proof of income Form 4506T (If taxes were not filed) required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income Notarized statement from patient stating zero income required as proof of income | |||||||||||||||||||||
| Delivery of Medication | ||||||||||||||||||||||
| Ship Time | 72 hours once received | |||||||||||||||||||||
| Delivery Options | Can be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card | |||||||||||||||||||||
| Application Process | ||||||||||||||||||||||
| App Process | With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application must be mailed back. Both the patient and doctor are notified in writing of acceptance or denial. Allow 4 weeks for processing and delivery of medication | |||||||||||||||||||||
| New Applications | New applications NOT accepted Can NOT apply for a new application via fax Can NOT apply for a new application via mail | |||||||||||||||||||||
| Refills | Refills NOT accepted Patients can NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail | |||||||||||||||||||||
| Re-Applications | Re-Applications NOT accepted Can Re-Apply via phone Can NOT Re-Apply via fax Can NOT Re-Apply via mail | |||||||||||||||||||||
| Appeals | Income Appeals NOT accepted Doctors can NOT apply for Income Appeals Hardship Appeals accepted on a case by case basis Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail | |||||||||||||||||||||
| Eligibility | ||||||||||||||||||||||
| Eligibility | The patient must not have any private nor public insurance and have an income at or below 200% of the Federal Poverty Level. The patient must also be a US resident. Patients who are enrolled in Medicare Part D, or in the 'Donut Hole' are not eligible for this program | |||||||||||||||||||||
| Limitations | Patients are NOT eligible if LIS is denied Patients are eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are NOT eligible if they are accepting Medicare Patients may be eligible if they are accepting Medicare part D on a case by case basis | |||||||||||||||||||||
| Appeals | ||||||||||||||||||||||
| Conditions | Appeals may be consider out-of-pocket expenses on a case by case basis | |||||||||||||||||||||
| Other Medications | ||||||||||||||||||||||
| Other Medications available in this program |
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