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Good Days Program
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6900 dallas Parkway
Suite 200 Plano, TX 75024
Phone
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(877)968-7233
Fax:
(214)570-3621
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Eligibility
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Insurance requirements not specified, this includes Medicare PartD. Income requirements for this program have not been disclosed. US residency requirements not specified. |
Who Can Apply
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Call to have application faxed, mailed, download from website or apply online. Return application via fax, mail or submit online. Patient and/or Doctor are notified of decision. |
Required
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Diagnosis/Medical Criteria not specified. Doctor gives prescription to patient. Patient must complete application, sign and attach required documents. |
Supply
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Refill process and limit not specified. Must re-enroll at the end of every calendar year. |
Ship To
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Shipping location not specified. |
Note
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Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. |
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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. | Jetrea injection |
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Printable Application Forms Applications that patients can fill out and bring to their doctor. | Download printable Form Good Days Program | (Requires Acrobat Reader)
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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. |
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. |
Supply
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As prescribed by Doctor |
Ship To
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Doctor's office, hospital, or pharmacy |
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. | Jetrea injection |
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Printable Application Forms Applications that patients can fill out and bring to their doctor. | Download printable Form | Download printable Form | (Requires Acrobat Reader)
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