Program Contact Info / Application Submission
Program	Berlex Patient Assistance Program ClimPro
Company	BerlexClimPro
Form	Download PDF
Address	6 West Belt, W66, Wayne, NJ 07470-6806
Phone	888-237-5394
Fax	973-305-3545
Program Details
Details	A 90-day supply is shipped to the doctor�s office. Refills require a re-order form to completed by either the doctor or doctor's office. A new application with documentation is needed once a year.
Program Requirements
Information	The doctor must fill out their section and sign the application. Patients must fill out their section, sign the application and attach proof of income.
Details	Insurance card required Drivers license required Proof of Income NOT required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income Notarized statement from patient stating zero income required as proof of income
Delivery of Medication
Ship Time	7-10 business days
Delivery Options	Can be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card
Application Process
App Process	Patients who are interested in this program cannot have any prescription insurance, must be ineligible for any government programs and have a low income based on the Federal Poverty Guidelines. Patients who are enrolled in any Government Prescription Programs or Private Prescription Plans, (such as; Medicare Part D, Medicaid, State-sponsored Prescription Assistance programs, employee insurance, military, retirement, or pension programs with drug coverage) is not eligible for this program. All applicants must be a US citizen or legal US resident. Each applicant is handled on a case-by-case basis.
New Applications	New applications NOT accepted Patients can NOT apply directly to the program Doctors can NOT apply directly to the program Advocates can NOT apply directly to the program Can apply for a new application via phone Can NOT apply for a new application via fax Can NOT apply for a new application via mail
Refills	Refills NOT accepted Patients can NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail
Re-Applications	Re-Applications NOT accepted Patients can NOT apply for Re-Applications Doctors can NOT apply for Re-Applications Advocates can NOT apply for Re-Applications Can Re-Apply via phone Can NOT Re-Apply via fax Can NOT Re-Apply via mail
Appeals	Income Appeals accepted Hardship Appeals accepted
Eligibility
Eligibility	Patients who are interested in this program cannot have any prescription insurance, must be ineligible for any government programs and have a low income based on the Federal Poverty Guidelines. Patients who are enrolled in any Government Prescription Programs or Private Prescription Plans, (such as; Medicare Part D, Medicaid, State-sponsored Prescription Assistance programs, employee insurance, military, retirement, or pension programs with drug coverage) is not eligible for this program. All applicants must be a US citizen or legal US resident. Each applicant is handled on a case-by-case basis.
Limitations	Patients are eligible if LIS is denied Patients are eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients are eligible if prescription coverage has been exhausted Patients are eligible if they are accepting Medicare Patients are eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted
Appeals
Conditions	Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses