Prescription Eligibility Guidelines

Eligibility Guidelines

Patient eligibility is based both on the patient and healthcare provider’s responses to questions in the Program Application. The following general criteria apply:

  • Patient must submit a complete application
  • Healthcare provider must complete an application and provide a prescription to the Specialty Pharmacy
  • Patient must be a legal resident of the United States
  • Patient may not reside in a hospital, nursing home, correctional facility or court appointed program or facility
  • Patient cannot have government health insurance or private health insurance with a prescription benefit
  • Patient cannot participate in a State Pharmacy Assistance Program
  • Patient must meet annual gross income requirements to participate in the reduced cost or no cost

All products provided through this program must be prescribed and intended to be used on-label.

Prescription Refill Requests

Initial Product Shipment

& Refill Requests

Once your application is approved the 1st shipment of product will be sent to you from the program’s Specialty Pharmacy.


You must request each additional product shipment (i.e. refills) during the enrollment or re-enrollment period by submitting a refill request. This request must include your case number and correspond with an active prescription on file at our Specialty Pharmacy to be approved. You may be required to re-attest to the information you supplied on your initial application to complete the request.


Each shipment will include a 1-month supply of the product. A minimum of 7 business days is needed for each shipment to be processed.

Our products


Our products

Aklief logo
Epiduo Forte logo
Epsolay Logo
Mirvaso logo
Oracea logo
Soolantra logo
Twyneo logo

How To Apply


Apply to the program by submitting an application form with the following information about you:

  • Contact details
  • Health insurance coverage
  • Household annual gross income and size
  • Healthcare provider's contact information


We will contact your healthcare provider to request that they provide supplemental information completing the application and send a prescription for the product to our Specialty Pharmacy.


A Patient Assistance Coordinator will review your application and notify you of the decision. If approved, you will be contacted to complete enrollment.

Frequently Asked Questions

You must request additional product shipments (i.e. refills) by submitting a refill request. More information on this process can be located in the Review the Initial Product Shipment & Refill Requests.

Product shipments are dispensed based on the prescription provided by the healthcare provider. You may not request multiple shipments at once and scripts for prescription products may only be written for 30 day supplies.

Product shipments are sent directly from our Specialty Pharmacy via UPS ground. Prescription products shipments are sent to the patient and Sculptra® product shipments are sent to the licensed injector.

Your case number will be provided in each interaction with our team. If you do not have this and would like to request a refill, you may provide your Social Security Number and birth date in place of your case number.

Once we receive your application, an automated email will be sent to your healthcare provider with a link to provide supplemental information that will complete the application. Your healthcare provider will then be provided the contact for our Specialty Pharmacy to send a prescription for the product.

1250 Patrol Road, Suite 100
Charlestown, IN 47111
NCPDP ID #1568560
NPI # 1285159152
NABP # 1568560
Fax:  1-877-235-1912


Contact a Program Coordinator

Monday - Friday | 8:00 am - 5:00 pm CT | 1-855-431-3737