| |
ACT Program
|
ACT Program
PO Box 18979
Louisville, KY 40261
Phone
:
866-363-6379
Fax:
866-363-6389
|
|
Eligibility
|
| > |
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
|
| > |
Anyone interested can call or download an application and it will be faxed, emailed or mailed to them. |
|
Required
|
| > |
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
|
| > |
Up to 30 day supply |
|
Ship To
|
| > |
Doctor's office or patient's home |
|
Note
|
| > |
Patients in need who appear not to qualify should still call. |
| |
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 |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|