What are the requirements for the Replenishment Program?

Facility Requirements

• Federal non-profit tax exempt status
• Must be a qualified facility that provides health care to patients regardless of their ability to pay (i.e. FQHC, FQHC-LA, free clinic, community health center)
• Must be in compliance with State Board of Pharmacy regulations in dispensing medications
• Computerized dispensing capabilities
• Medical Director with current license and DEA number
• Majority of patients with annual household income at or below 250% Federal Poverty Level (FPL)
• Dedicated staff and effective processes and controls in place to perform and document patient eligibility screening according to program requirements
• Ability to retain records: patient application and supporting documentation including patient proof of income and dispensing records for at least 3 years
• Assign a key clinic staff member (involved with medication orders) and a back up staff member for ordering and corresponding with Direct Relief USA
• Ability to maintain medication management policies and procedures specific to program requirement, including: patient screening, dispensing to qualified patients, order request through drug utilization reporting and record retention
• Submit to audit to demonstrate medication dispensing compliance with program requirements 

Patient Requirements

• Registered patient of certified clinic
• Uninsured with no public or private assistance for medications
• Income at or below 250% of FPL and adjusted for family size
• Provision of Social Security Number if available
• United States resident (undocumented patients are eligible to receive program drug if they are residing in the US)
• Completion of required application and annual furnishing of income documentation and residency verification (i.e. most recent tax-return, pay-stubs, unemployment statement)
• Willing to sign a consent form for release of patient information for audit purposes
• Patients who are migrant and/or homeless are presumed eligible, an attestation or form verifying eligibility must be completed and kept on file
• Patient has a valid prescription for one of the program medications