| |
OMIDRIAssure Equal Access Patient Assistance Program
|
,
Phone
:
(877)664-3742
Fax:
(855)664-3741
|
|
Eligibility
|
| > |
This program provides brand name medications at no or low cost and is for Healthcare Professionals only. The patient must be enrolled in OMIDRIAssure prior to cataract surgery or intraocular lens replacement. Income requirements for this program have not been disclosed. Patients must be a US resident. |
| Who Can Apply
|
| > |
Doctors or doctor's office must call or download the application. |
|
Required
|
| > |
Doctors must complete and sign a portion of the application. Patients must complete a portion of the application, sign and attach required documents. |
|
Supply
|
| > |
1 dose |
|
Ship To
|
| > |
Doctor's office or specific site |
|
Note
|
| > |
Resources for HEALTHCARE PROFESSIONALS ONLY.
Patient must be enrolled in OMIDRIAssure prior to cataract surgery or intraocular lens replacement.
This program also provides co-pay and reimbursement assistance. |
| |
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.
|
| Omidria solution |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|