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EYLEA4U
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PO Box 220578
Charlotte, NC 28222
Phone
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855-395-3248
Ext 4
Fax:
888-335-3264
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Eligibility
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Patients must be uninsured or underinsured. Medicare Part D recipients are not eligible. Patients must have a gross annual household income at or below $100,000 and must be a US resident. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or download one. |
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Required
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Docotors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income. |
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Supply
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Varies |
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Ship To
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Doctor's office or specific site |
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Note
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This program also provides copay 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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| Eylea |
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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 |
| Download printable Form |
(Requires Acrobat Reader) 
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