| Pharmaceutical Company | Roche Labs |
| Program Address | Medical Needs Department Roche Laboratories 340 Kingsland St. Nutley, NJ 07110-1199 |
| Toll Free Phone Number | 800-285-4484 |
| Fax Number | 973-562-2765 |
| Guidelines and Notes | Call between 9 and 4PM EST. PROGRAM NOT INTENDED FOR CLINICS, HOSPITALS OR INSTITUTIONS. Patients should be ineligible for any type or prescription coverage. They will only send the application to the doctor's office and it can't be copied! Klonopin and Valium will only be shipped to a physician's registered DEA address. |
| Initiating Enrollment | Will send form to doctor at social worker's request, or doctor can call. It is a two-part carbonless form. Doctor retains yellow copy for file. |
| Health Provider's Role | Doctor completes, signs, includes DEA #. The prescription is incorporated into the application. |
| Patient's Role | Minimal information about household size and income. PATIENT SIGNATURE REQUIRED. |
| How Dispensed | Sends medicine to physician's registered DEA address -- provide street address, NOT PO BOX!! |
| Amount Dispensed | 3 month supply -- takes up to 3 weeks from receipt of appli cation |
| Refills | Use entirely new application every 3 months. |
| Limit | Indefinitely |