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Commitment to Care for Hepatitis C Medications
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PO Box 18725
Louisville, KY 40261
Phone
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800-521-7157
Ext OPT 2
Fax:
800-683-7855
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and meet income guidelines that are not disclosed. |
| Who Can Apply
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With the patient's permission, anyone concerned can call for an application. |
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Required
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The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Up to a 30-day supply |
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Ship To
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Either Doctor's office or Patient's home |
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Note
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With the patient's permission, anyone concerned can call for an application. |
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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.
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| Intron-A Injection |
| Peg-Intron (peginterferon alfa-2b) |
| Rebetol (ribavirin) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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