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Patient Assistance Information

Jetrea Care

ATTN Jetrea Care
2730 S. Edmonds Ln, Suite 300
Lewisville, TX 75067
Phone :
> 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
> Patients or healthcare providers can call to have an application faxed or it can be downloaded.
> Doctors must complete a section of the application and sign. Patients must complete a section, sign, and attach proof of income and residency.
> As prescribed by Doctor
Ship To
> Doctor's office, hospital, or pharmacy
> 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.
Jetrea injection
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
Download printable Form
(Requires Acrobat Reader