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.

PO Box 1308
San Bruno, CA 94066

TEL: 866-698-7339


FAX: 866-676-4069
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Ozurdex Patient Assistance Program Application

 

Brand Name Medications Covered

 
  • Ozurdex implant; intravitreal
 

Generic Name

 
  • dexamethasone implant; intravitreal
 

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 or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income and other requested documentation
Decision Communicated Doctor notified
Decision Timeframe 2-4 business days
   

Medication

Amount/Supply Varies
Sent To Doctor's office
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 Retina Coverage Connection (ARCC) now offers a Patient Copay Assistance Program. Please visit www.AllerganRCC.com for details.


Updated July 07, 2017