rxhelp360.org
| Drug Information | ||||||
| Drug | Vagifem | |||||
| Generic Equivalent | estradiol vaginal tablets | |||||
| Topic | Hormone | |||||
| Program Contact Info / Application Submission | ||||||
| Program | Novo-Nordisk Hormone Therapy Patient Assistance Program | |||||
| Company | NovoNorHorm | |||||
| Form | Download PDF | |||||
| Address | PO Box 181640, Lousville, KY 40261 | |||||
| Phone | 866-668-6336 | |||||
| Fax | 866-441-4190 | |||||
| Program Requirements | ||||||
| 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 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 | 3-4 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 | ||||||
| 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 NOT accepted Patients can NOT apply for Re-Applications Doctors can NOT apply for Re-Applications Advocates can NOT apply for Re-Applications Can Re-Apply via phone Can NOT Re-Apply via fax Can NOT Re-Apply via mail | |||||
| Appeals | Income Appeals NOT accepted Patients can apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals NOT accepted Patients can apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail | |||||
| Eligibility | ||||||
| Limitations | Patients may be eligible with existing prescription coverage on a case by case basis Patients may be eligible if prescription is not covered on a case by case basis 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 may be eligible if they are accepting Medicare part D on a case by case basis Patients may be eligible if the medication is not covered under Medicare on a case by case basis 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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