Program Contact Info / Application Submission
Program	Berlex Oncology Camcare
Company	BerlexOnc
Form	Download PDF
Address	PO Box 221289, Charlotte, NC 28222-1289
Phone	800-321-4669
Fax	800-513-1824
Website	http://www.berlex.com/html/index.html
Program Details
Details	Medication is shipped to the doctor�s office.�The doctor or doctor�s office must contact the company to request refills.�A new application is needed every 6-months.
Program Requirements
Information	The doctor must fill out their section and sign the application. The Patient must fill out their 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 income required as proof of income Form 4506T (If taxes were not filed) NOT 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
Delivery of Medication
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 interested can call and request an application. Applications are faxed to the doctor�s office. Completed applications can either be faxed or mailed back.
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 apply for refills Doctors can NOT apply for refills Advocates can apply for refills
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
Eligibility
Eligibility	Patients can have no insurance coverage and�meet the income guidelines which are not disclosed.��Patients must be a US citizens.�If the patient has insurance; which does not cover the medication being requested, with proof of non-coverage the patient will be considered on a case-by-case basis and may qualify.
Limitations	Patients are NOT eligible if LIS is denied Patients may be eligible with existing prescription coverage on a case by case basis 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 may be eligible if they are accepting Medicare part D on a case by case basis Patients are NOT 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