|
|
|
|
Eligibility Criteria |
|
| |
Patients must meet all of the following guidelines to qualify for Bridges to Access:
Be a United States resident
Have no prescription drug benefits through any insurer/payer/program*
*Patients who are Medicare-eligible, but not enrolled in a Medicare Part D Prescription Drug Plan must apply and be denied full Low Income Subsidy (LIS) assistance if their household income is less than 135% of the Federal Poverty Level.
Have gross monthly household income at or below:
The following table represents 250% of the 2008 Poverty Guidelines.
Please call 1-888-825-5249 for more information.
- 48 Contiguous States and District of Columbia
Size of Family Unit |
Monthly Gross Income |
1 |
$2,166.67 |
2 |
$2,916.67 |
3 |
$3,666.67 |
4 |
$4,416.67 |
For each additional
person, add |
$750.00 |
- Alaska
Size of Family Unit |
Monthly Gross Income |
1 |
$2,708.33 |
2 |
$3,645.83 |
3 |
$4,583.33 |
4 |
$5,520.83 |
For each additional
person, add |
$937.50 |
- Hawaii
Size of Family Unit |
Monthly Gross Income |
1 |
$2,491.67 |
2 |
$3,354.17 |
3 |
$4,216.67 |
4 |
$5,079.17 |
For each additional
person, add |
$862.50 |
| Proof of income for the past 30 days will be needed. |
| |
Proof of Household Income
After the enrollment phone call, the Advocate should send in
proof of current income and other requested documents along with the enrollment form and a
prescription with indicated refills if needed for mail order refills (if necessary).
Proof of Income should be for the previous 30 day period
and should be for all people who contribute to or are dependent
on the patient’s household income. Documentation varies
by income type as explained below. Any of the following documents
are acceptable and document requirements will be communicated
to the advocate if the patient is eligible.
- Salary/wages:
- One month consecutive documentation including pay stubs
- Pay stub with year-to-date income
- Letter on company letterhead
- Notarized statement from employer
- Bank statement
- Self employment income:
- 1099 form including Schedule C from the most recent
tax return
- Copy of most recent check or check stub
- Social Security Retirement:
- Benefit statement for current year
- Copy of most recent bank statement showing direct deposit
- Copy of most recent check or check stub
- Supplemental Security Income:
- Benefit statement for current year
- Copy of most recent bank statement showing direct deposit
- or copy of most recent check or check stub
- Social Security Disability:
- Benefit statement for current year
- Copy of most recent bank statement showing direct deposit
- Copy of most recent check or check stub
- Unemployment:
- Unemployment award letter on company letterhead indicating amount and time period
covered
- Copy of most recent unemployment check or unemployment
check stub
- Alimony/Child support:
- Court award letter indicating amount and time period covered
- Child Support Enforcement Agency letter
- Letter from attorney stating amount and time period covered
- Copy of one month's check
- Bank statement with amount indicated
- Veterans Benefits:
- Benefit statement or current year
- Copy of most recent bank statement showing direct deposit
- Copy of most recent check
- Check stub
- Pension/Retirement:
- Benefit statement for current year
- Copy of most recent bank statement showing direct deposit
- Copy of most recent check
- Check stub
- Other:
- Benefits statement
- Award letter
- Bank statement from payer/source
- Copy of check(s)
- Judgment statement
|
|
|
