Program Contact Info / Application Submission
Program	PROCRITline (Leustatin)
Company	OrthoBioLue
Address	P.O Box 1016 San bruno, CA 94066
Phone	800-609-1083
Fax	800-987-5572
Program Requirements
Details	Insurance card NOT required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero incomeNOT 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 NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income NOT required as proof of income
Delivery of Medication
Delivery Options	Can NOT be delivered directly to the patient Can be delivered directly to the doctor Shipped as a voucher card
Application Process
New Applications	New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail
Refills	Refills accepted Patients can NOT apply for refills Doctors can apply for refills Advocates can NOT apply for refills Can NOT 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 NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail
Appeals	Income Appeals accepted Patients can NOT apply for Income Appeals Doctors can apply for Income Appeals on a case by case basis Advocates can apply for Income Appeals on a case by case basis Hardship Appeals accepted on a case by case basis Patients can apply for Hardship Appeals on a case by case basis Doctors can apply for Hardship Appeals on a case by case basis Advocates can apply for Hardship Appeals on a case by case basis Can apply for an appeal via phone on a case by case basis Can apply via fax Can apply for an appeal via mail
Eligibility
Limitations	Patients are eligible if LIS is denied Patients are NOT eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are 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 eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted
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 on a case by case basis