The Equal Epinephrine Foundation of America
Our application and services are free and will always be free!
Type of Insurance UninsuredMedicaid/Government insurancePrivate insurance
If you chose private insurance, please list their name, your total deductible and how much you have paid towards it here
First Name Last Name
Who is this for? —Please choose an option—MeMy ChildA Family Member over the age of 18
Phone Number Email Address City Zipcode
Annual Household Income —Please choose an option—Less than $10,000$10,001 - $20,000$20,001 - $30,000$30,001 - $40,000$40,001 - $50,000$50,001 - $60,000$60,001 - $70,000$70,001 - $85,000$85,000 - $97,400$97,401 - $100,000$100,001 - $150,000$150,000+
Household size (If its only you, input 1)
How much did you last pay for Epinephrine?
My prescription is for 0.1 mg0.15 mg0.3 mg