Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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EYLEA4U

This program provides brand name medications at no or low cost

Provided by: Regeneron Pharmaceuticals, Inc.

PO Box 220578
Charlotte, NC 28222-0578

TEL: 855-395-3248


FAX: 888-335-3264
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

EYLEA4U Enrollment Form

EYLEA4U Enrollment Form (Spanish)

 

Medications

  • aflibercept injection; iv (Eylea) Injection; IV
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? No
Income Gross annual household income at or below $100,000
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be residing in the US or US territory
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or specific site
Delivery Time Not specified
Refill Process Doctor/Doctor's office must contact the Program
Limit Not specified
Re-application New application yearly
   

Additional Information

This program also provides copay and reimbursement assistance.

Updated July 08, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Good Days Program

This is a copay assistance program

Provided by: Good Days from CDF

Attn: Enrollment
2611 Internet Blvd.
Suite 105
Frisco, TX 75034

TEL: 877-968-7233


FAX: 214-570-3621
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Good Days Program Patient Enrollment Application (pages 3-5)

Good Days Program Enrollment Information Pages (pages 1 & 2)

Good Days Program Patient Enrollment Application (pages 3-5) (Spanish)

Good Days Program Enrollment Information Pages (pages 1 & 2) (Spanish)

 

Medications

  • aflibercept injection; iv (Eylea) Injection; IV
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Not specified
Income At or below 500% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Yes and have social security number
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax, mail or submit online
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Must re-enroll at end of calendar year
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Updated September 10, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • aflibercept injection; iv (Eylea) Injection; IV
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.

Updated September 01, 2020