The ECR Pharmaceuticals’ Patient Assistance Program is designed to help patients who are prescribed an ECR prescription product, who meet certain income guidelines, and who are not eligible for prescription drug assistance through federal, state, or private programs. The products covered by this program and an application for patient assistance follows. The application form may be printed and taken to your physician’s office, or the office may be able to print the form for their patients by accessing it through the firm’s website (www.ecrpharma.com). Please note that the form must be fully completed, signed by both the patient and his or her physician, and submitted to ECR by the physician. If qualified, the medication will be sent to the patient’s physician for dispensing with appropriate dosing instructions.
 ECR Pharmaceuticals' Patient Assistance Program Application Form
To be eligible for the ECR Patient Assistance Program, the
patient/family income must not exceed twice
the amount of the federal guidelines listed below.
2011
HHS Guidelines
Persons in
Family or Household |
48 Contiguous
States and D.C. |
Alaska |
Hawaii |
| 1 |
$10,890 |
$13,600 |
$12,540 |
| 2 |
14,710 |
18,380 |
16,930 |
| 3 |
18,530 |
23,160 |
21,320 |
| 4 |
22,350 |
27,940 |
25,710 |
| 5 |
26,170 |
32,720 |
30,100 |
| 6 |
29,990 |
37,500 |
34,490 |
| 7 |
33,810 |
42,280 |
38,880 |
| 8 |
37,630 |
47,060 |
43,270 |
For each additional
person, add |
3,820 |
4,780 |
4,390 |
|
SOURCE: Federal Register, (Volume 76, Number 13) January
20, 2011, pp. 3637-3638
|
