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Jetrea Care
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ATTN Jetrea Care
2730 S. Edmonds Ln, Suite 300
Lewisville, TX 75067
Phone
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Fax:
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Eligibility
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Patients must be uninsured or rendered uninsured, have a gross annual household income at or below $100,000 and must reside permanently in the US or Puerto Rico. Patients must have diagnosis of Vitreomacular Adhesion, Vitreomacular Traction. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or it can be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section, sign, and attach proof of income and residency. |
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Supply
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As prescribed by Doctor |
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Ship To
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Doctor's office, hospital, or pharmacy |
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Note
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This program also provides co-pay and reimbursement assistance. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Jetrea injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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