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ACT Program
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ACT Program
PO Box 18979 Louisville, KY 40261
Phone
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866-363-6379
Fax:
866-363-6389
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Eligibility
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This program provides brand name medications at no or low cost to patients that are uninsured or underinsured. Medicare Part D recipients are eligible. Patients must be at or below 500% of the federal poverty level. Patients must be a US resident and be treated by a US licensed healthcare provider. |
Who Can Apply
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Anyone interested can call or download an application and it will be faxed, emailed or mailed to them. |
Required
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Doctors must complete, sign and attach a prescription to the application. Patients must complete and sign and the completed application can be sent by fax or mail. |
Supply
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Up to 30 day supply |
Ship To
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Doctor's office or patient's home |
Note
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Patients in need who appear not to qualify should still call. |
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Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now. Click drug logo or drug name to start online application. |
Noxafil tablet; delayed release |
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Printable Application Forms Applications that patients can fill out and bring to their doctor. |
Download printable Form |
(Requires Acrobat Reader)
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