| |
Program Details
RAYNER SURGICAL, INC.
OMIDRIAssure Program
Omidria solution
(phenylephrine/ketorolac tromethamine solution)
|
| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-877-664-3742 |
Provider Phone: |
|
| Fax: |
1-855-616-7741 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Program offers co-pay assistance, reimbursement support, and patient assistance programs for eligible patients.
To be eligible for assistance, patients must be enrolled 5 days prior to surgery. |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
Not
Published |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
DEA
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Provider
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
1 Vial |
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
|
Last Updated: 05/09/2025
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
Patient Certification Form
|
|
