Contact info
- Phone
- 1-855-395-3248
- Fax
- 1-888-335-3264
- Mailing address
- PO Box 220578Charlotte, NC 28222-0578
Eligibility
- Patient must be uninsured or underinsured.
- Patients with Medicare Part D are not eligible.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Other income rules
- Gross annual household income at or below $100,000
- 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
- Both DEA and state license numbers
- 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
- Not published
- Staying enrolled
- New application every 12 months
- New proof of income every 12 months
More from the program
Co-pay and reimbursement assistance is also available.
Medications covered
- Eylea HD (aflibercept)
- Eylea injection (aflibercept)