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See the program website for more details about requirements for each medication. Income eligibility varies based on your prescription. Most people without insurance and with limited incomes will qualify. You can receive up to 12 months of medication at no cost to you if you are approved. You will need your doctor to help you fill out a form that you can submit by mail or fax. Go to the program website and follow the instructions on the How to Apply page. The following program is available for this drug. You’ll need to apply through each program, either online, over the phone, or with your doctor's help. Eligibility is often based on income, insurance or Medicare status, and other factors. Many programs are available from federal and state governments, non-profits, manufacturers, and other organizations to help you get the drugs you need at a reduced cost.

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