Contact info
- Fax
- 1-844-501-7161
Eligibility
- Patient must be uninsured or insurance will not cover the medication.
- Patients with Medicare Part D are not eligible.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Other income rules
- Based on total adjusted annual household income of $100,000 or less
- 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
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- No refills
- Staying enrolled
- Not published
Medications covered
- Iluvien (fluocinolone acetonide intravitreal implant)