Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

Ozurdex Patient Assistance Program

For Healthcare Professionals Only

Provided by: Allergan, Inc.


TEL: 866-698-7339


FAX: 866-676-4069
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Ozurdex Patient Assistance Program Patient Enrollment Form

 

Brand Name Medications Covered

 
  • Ozurdex
 

Generic Name

 
  • dexamethasone
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Yes, if medication is not covered
Income Gross annual household income at or below $100,000
Diagnosis/Medical Criteria Must provide diagnosis code
US Residency Required? United States or Puerto Rico
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Doctor notified
Decision Timeframe 2-4 business days
   

Medication

Amount/Supply Varies
Sent To Doctor's office or specific site
Delivery Time Within 2 weeks
Refill Process Not specified
Limit Not specified
Re-application New application every 12 months
   

Additional Information

For US HEALHCARE PROFESSIONALS ONLY: Allergan now offers a Patient Copay Assistance Program. Please visit www.AllerganEyeCue.com for details.


Updated November 30, 2017