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BENEFITS INVESTIGATION FORM FOR (aflibercept) INJECTION Phone: 1855EYLEA4U (18553953248), Option 4Section 1.1Support RequestedPreliminary Benefits InvestigationSection 2.1Fax: 18883353264www..comAnticipated.

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Call 1-855-EYLEA4U (1-855-395-3248) and press Option 4 Monday through Friday 9 AM through 8 PM Eastern Time— your EYLEA4U Support Specialist will guide you through the enrollment process. The Co-Pay Card Program would cover the balance of $485 if you have not exceeded the $10,000 per-year limit.

® Medicare Coverage Medicare Part B may cover treatment if it's deemed medically necessary to treat age-related macular degeneration. ® is a medication typically used to treat macular degeneration due to age, macular swelling, diabetic macular swelling and diabetic retinopathy.

If you have insurance, your insurance company may require prior authorization before it covers . This means the company and your doctor will discuss in regard to your treatment. The insurance company will then determine whether to cover the medication.

For , a treatment for macular degeneration, Medicare Advantage enrollees would face average cost-sharing liability of $2,100 at a 20% coinsurance rate and up to $5,200 at a 50% coinsurance rate, assuming the plan pays the same price as traditional Medicare.

To report SUSPECTED ADVERSE REACTIONS, contact Regeneron at 1-855-395- 3248 or FDA at 1-800-FDA-1088 or .fda.gov/medwatch. For ophthalmic intravitreal injection. must only be administered by a qualified physician.

About The Commercial Copay Card Program If you have commercial insurance, you may be eligible to pay as little as $0 for each treatment.*,† You may qualify for copay assistance if: 1. You have commercial or private insurance that covers . 2. You are receiving for an FDA-approved indication.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232