Contact info
- Phone
- 1-866-402-5622
- Fax
- 1-866-500-0987
Eligibility
- Eligibility determined on a case-by-case basis.
- Patients with Medicare Part D may be eligible, contact program for details.
- Income based on Federal Poverty Level.
- 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
- 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
- Not published
Getting the medication
- Patient receives
- Medication
- Shipped to
- Not published
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- BKEMV (aflibercept-ayyh)