rxhelp360.org
| Program Contact Info / Application Submission | ||||||||||||||||||||||||||||
| Program | Dermik Patient Assistance Program | |||||||||||||||||||||||||||
| Company | Dermik | |||||||||||||||||||||||||||
| Form | Download PDF | |||||||||||||||||||||||||||
| Address | PO Box 651 Somerville, NJ 08876 | |||||||||||||||||||||||||||
| Phone | 1-866-268-7326 | |||||||||||||||||||||||||||
| 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 | Proof of Income NOT required | |||||||||||||||||||||||||||
| Delivery of Medication | ||||||||||||||||||||||||||||
| Ship Time | 4 Weeks | |||||||||||||||||||||||||||
| Delivery Options | Can NOT be delivered directly to the patient Can NOT be delivered directly to the doctor | |||||||||||||||||||||||||||
| 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 | |||||||||||||||||||||||||||
| 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 | |||||||||||||||||||||||||||
| Other Medications | ||||||||||||||||||||||||||||
| Other Medications available in this program |
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