Contact info
- Phone
- 1-877-664-3742
- Fax
- 1-855-616-7741
Eligibility
- Program offers co-pay assistance, reimbursement support, and patient assistance programs for eligible patients.
- To be eligible for assistance, patients must be enrolled 5 days prior to surgery.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- Not published
- US citizenship or residency required
- Yes
Not sure where your income falls? See this year's federal poverty guidelines (opens in a new tab).
Application process
- Documents to attach
- Proof of income
- Prescriber license number
- NPI number
- DEA number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider
- Supply per shipment
- 1 Vial
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Omidria solution (phenylephrine/ketorolac tromethamine solution)