Program Details
OCULAR THERAPEUTIX, INC.
Dextenza 360
Dextenza
(dexamethasone ophthalmic insert)
|
| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-800-339-8369 |
Provider Phone: |
|
| Fax: |
1-855-518-7564 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Program helps the uninsured, government insured, and commercially insured patients with no payer coverage for DEXTENZA.
Patients with Medicare Part D may be eligible, contact program for details.
|
| Income at or below: |
Single |
|
500
% FPL |
| |
Couple |
|
500
% FPL |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
Yes |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Not Published
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
|
Last Updated: 05/08/2020
www.RxAssist.org
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