Program Details
ALIMERA Sciences, INC.
AccessPlus Patient Assistance Program
Iluvien
(fluocinolone acetonide intravitreal implant)
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CONTACT
INFO |
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Address: |
, |
Phone: |
1-844-445-8843, opt. 3 |
Provider Phone: |
|
Fax: |
1-844-501-7161 |
Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Patient must be uninsured or insurance will not cover the medication.
Patients with Medicare Part D are not eligible.
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Income at or below: |
Single |
|
% FPL |
|
Couple |
|
% FPL |
Income at or below: |
Not
Published |
Other Income
Requirements: |
Based on total adjusted annual household income of $100,000 or less |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
Yes |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
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MEDICATION |
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Receives: |
Medication
|
Shipped To: |
Provider
|
Quantity in
Shipment: |
Not Published
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Delivery Time: |
Not Published
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Re-application
Policy: |
Not Published |
Refill Policy: |
No refills
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Other Information: |
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Last Updated: 04/17/2024
www.RxAssist.org
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