Contact info
- Phone
- 1-866-272-8838
- Fax
- 1-866-272-8839
Eligibility
- Patient must have no prescription coverage or been denied coverage and meet program income guidelines which are based on the federal poverty level.
- Program will provide patient assistance referrals for eligible patients.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- US citizenship or residency required
- Not published
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
Getting the medication
- Patient receives
- Varies
- Shipped to
- Not published
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Retisert (fluocinolone acetonide intravitreal implant)
- Visudyne (verteporfin for injection)
- Xipere (triamcinolone acetonide injectable suspension)