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| Drug Information | ||||||||||||||||||
| Drug | MetroGel Vaginal | |||||||||||||||||
| Generic Equivalent | metronidazole vaginal gel | |||||||||||||||||
| Topic | Antibiotic | |||||||||||||||||
| Program Contact Info / Application Submission | ||||||||||||||||||
| Program | Graceway Pharmaceuticals Patient Assistance Program | |||||||||||||||||
| Company | Graceway Pharmaceuticals | |||||||||||||||||
| Form | Download PDF | |||||||||||||||||
| Address | PO Box 8202 Somerville, NJ 08876 | |||||||||||||||||
| Phone | 866-628-6498 | |||||||||||||||||
| Fax | 866-838-5820 | |||||||||||||||||
| Website | http://www.chestervalleypharma.com/ | |||||||||||||||||
| Program Details | ||||||||||||||||||
| Details | A new application with new prescription is needed every 3 months for refills. If denied, both patient and provider will be notified in writing. | |||||||||||||||||
| Program Requirements | ||||||||||||||||||
| Information | All sections must be completed. Attach the following items: brand name prescription for a 3 month supply; copy of patient's most recent Federal Tax Return or Social Security Income | |||||||||||||||||
| Details | Insurance card required 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 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 | |||||||||||||||||
| Other Requirements | Must re-apply every 3 months | |||||||||||||||||
| Delivery of Medication | ||||||||||||||||||
| Ship Time | 4-5 weeks | |||||||||||||||||
| 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 | The doctor must fill out a section, sign the application and attach a prescription for 90 days. The patient must fill out a section, sign the application and attach proof of income. | |||||||||||||||||
| New Applications | New applications NOT accepted Patients can NOT apply directly to the program Doctors can NOT apply directly to the program Advocates can NOT apply directly to the program Can apply for a new application via phone 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 accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can Re-Apply via fax Can Re-Apply via mail | |||||||||||||||||
| Appeals | Income Appeals accepted Hardship Appeals accepted Can apply via fax Can apply for an appeal via mail | |||||||||||||||||
| Eligibility | ||||||||||||||||||
| Eligibility | Legal US resident. Patient must not have/not be eligible for any government or private prescription coverage. Patient must not have Medicare D prescription coverage. Patient 's total household income must be at or below %200 of the federal poverty level. Medical and prescription expenses will be considered when financially qualifying for program. | |||||||||||||||||
| Limitations | Patients may be eligible if LIS is denied on a case by case basis Patients are NOT eligible with existing prescription coverage Patients are NOT eligible if prescription is not covered Patients may be eligible if prescription coverage has been exhausted on a case by case basis Patients are NOT eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients may be eligible if Medicare coverage has been exhausted on a case by case basis | |||||||||||||||||
| Appeals | ||||||||||||||||||
| Conditions | Appeals may be consider out-of-pocket expenses on a case by case basis Appeals may be consider total medical expenses on a case by case basis Appeals may be made before the patient has been denied | |||||||||||||||||
| Other Medications | ||||||||||||||||||
| Other Medications available in this program |
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