Contact info
- Phone
- 1-800-222-6885
- Fax
- 1-866-483-1305
- Mailing address
- PO Box 270Somerville, NJ 08876
Eligibility
- Eligibility is determined on case-by-case basis.
- Patients who are uninsured or underinsured and are unable to afford the cost of therapy may be eligible for enrollment.
- Patients with Medicare Part D may be eligible. Contact program for details.
- Income limit, single
- 600% of the federal poverty level
- Income limit, couple
- 600% of the federal poverty level
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- Yes
- 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
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider and patient
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider or patient
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Please call 1-800-222-6885 to request refills.
- Staying enrolled
- Not published
Medications covered
- Alphagan P ophthalmic solution (brimonidine tartrate ophthalmic solution)
- Durysta (bimatoprost implant)
- Lumigan (bimatoprost ophthalmic solution)
- Ozurdex (dexamethasone intravitreal implant 0.7mg)
- Restasis (cyclosporine)
- XEN Sterile Injector (XEN sterile injector)