Requirements
Below are the minimun qualifications to enroll into The Medicine Cabinet. Meeting the minium qualifications for enrollment into this program does not ensure you will meet the minimum requirements for the medication programs in which you are inquiring. Please contact our office for more information.
HOW TO QUALIFY:
- Patient can NOT have prescription coverage
- Patient must be at or below the 200% Poverty Income*.
- Patient must take prescribed medication and can not afford to buy them with the income allotted.
WHAT TO BRING:
- List of your medications
- Include the dosage, how often you are taking it, and the prescribing doctor.
- Prescribing Physician's Information
- Include address, phone number. List any and all doctors that will be prescribing you medication.
- Proof of Income: (You must supply at least one of the following)
- Tax Form 1040 (from previous year)
- If you did not file taxes, you will need to complete a Form 4506T
- W-2
- Paycheck Stubs (for the past MONTH)
- Social Security/ Disability Statement
- Unemployment Benefits Statement
**If you do not have an income, please contact our office.
- Correspondence
- Photo ID
- Green Card (if applicable)
- Any denial letters from any private insurance or government program
FEES:
- $25 – Annual Enrollment fee
- $25 – Monthy memeberships fee
- You will be responsible for any pharmaceutical fees corresponding with generic medications ( please call for details)
First payment of $50 is due at time enrollment, the month fee of $25 will be billed.
*Poverty Chart Source: Federal Register Vol. 73, No. 15, January 23, 2008, pp. 3971-3972. Monthly and yearly percentage data calculated by FHCE and rounded to the nearest dollar.
