(1) A person wishing to participate in the insulin distribution program can obtain an application from any county health department. The application is form number DH2105, 3/07, “”Insulin Distribution Program Application”” which is incorporated herein by reference. A copy of this form can be obtained from any county health department or its designated agent.
    (2) Every 12 months a client must submit a completed application to the county health department or designated agent of the department who will approve the application based upon the following criteria:
    (a) The applicant must be a bona fide Florida resident;
    (b) The applicant must be unable to pay for insulin because the applicant:
    1. Is uninsured, or lacking insurance that provides coverage for insulin; and,
    2. Has a net family income at or below 100% of Federal poverty guidelines; and,
    3. Has no more than $2,500.00 per family in private funds, bank accounts or assets other than their homestead to defray the cost.
    (c) The applicant must submit a current prescription for insulin.
    (d) The applicant must self-declare assets, insurance coverage, family size and residency.
    (e) The applicant must sign a statement of income, specifying all gross income available to the applicant and the number of people dependent upon that income. The statement shall include a signed acknowledgement that the statement is true at the time it is made and that the person making the statement understands that the CHD will attempt to verify the statement.
    (3) The county health department will verify the applicant’s income as follows:
    (a) Verification may be made by telephone, in written form, or by face to face contact. Verification does not require written documentation to confirm an applicant’s statement. Verification can include:
    1. A statement from a government agency which attests to the applicant’s financial status.
    2. A statement from the applicant’s or family member’s employer.
    3. Pay stubs for four consecutive weeks.
    4. A statement from a source providing unearned income to the applicant or family unit.
    (b) If the CHD is unable to verify wages paid or an employer will not verify wages paid, the statement provided by applicant may be accepted as accurate.
    (c) If the applicant declares zero income, the CHD may require the applicant to describe in detail their living circumstances and how they obtain basic necessities such as food, shelter, clothing, medical care, and transportation.
    (4) The county health department has authority to make the final determinations of eligibility for the insulin distribution program.
    (5) If the Department of Health’s pharmaceutical budget permits, applicants or current insulin distribution program clients with a net family income of 101-200% of Federal poverty guidelines that meet the requirements in paragraph (2)(a), and subparagraphs (2)(b)1. and 3., above, will be eligible for the insulin distribution program or to continue in the program and receive insulin at reduced cost based on a sliding fee scale as set forth in Fl. Admin. Code Chapter 64F-16
    (6) If an otherwise unqualified applicant, as defined above, is temporarily without current financial resources to purchase insulin, the county health department may provide a one month supply of insulin to this applicant once annually.
    (7) If at any time the applicant experiences a change in status, which could affect his or her eligibility, the applicant must report this change to the county health department within thirty days of this change.
    (8) The county health department will assist clients receiving insulin through this program, who become or are found to be ineligible, in locating another source of insulin. The county health department will continue to provide insulin to the client until another source can be found for up to 1 year after the determination of ineligibility.
    (9) County health departments or their designated agents will maintain records regarding their dispensing of insulin under this program for five years. These records shall include a copy of the Insulin Distribution Program Application and a copy of the applicant’s prescriptions for insulin.
Rulemaking Authority 385.204 FS. Law Implemented Florida Statutes § 385.204. History-New 12-19-00, Amended 3-2-08.