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EYLEA4U® Patient Assistance Program

Helps eligible patients who have unmet medical needs, are uninsured, or lack coverage receive EYLEA® (aflibercept) Injection free of charge.

Effective May 1, 2017:
Enhanced PAP to help eligible patients
receive EYLEA

Patient eligibility criteria

  • Uninsured or lacks coverage for EYLEA
  • Must be a resident of the United States or its territories or possessions
  • Must have a completed EYLEA4U Enrollment Form with patient signature in Section 6.3
  • Demonstrates financial need
    • Annual household adjusted gross income (AGI) must satisfy 1 of the following:
      • AGI is $100,000 or less
        OR
        AGI is $100,001–$150,000 AND patient’s out-of-pocket drug costs for EYLEA account for ≥3% of patient’s AGI
        • Documentation of patient’s out-of-pocket drug costs for EYLEA is required and can include:
          • Practice receipt of patient payment for EYLEA, which must include the amount paid specifically for EYLEA; practice billing record; or statements showing the patient’s EYLEA drug expenses have been billed
EYLEA4U will be able to independently verify a patient’s income with our new income validation tool.*

Patients are eligible for assistance for up to 1 year and must reapply annually.

*If the income validation tool is unable to return results, the patient will be required by EYLEA4U to provide proof of income. Proof of income may also be requested at any time for audit/verification.

Applying for the Patient Assistance Program

To apply
  • Fax completed form to 1-888-335-3264 or submit electronically via the EYLEA4U e-Portal*

*A completed and patient-signed form must be retained on file at the office for submissions entered via the e-Portal.

Patient Assistance Program Process

Once the Enrollment Form requesting the Patient Assistance Program is received, a Reimbursement Specialist will:
Verify the patient’s eligibility criteria and physician's decision to treat
  • Uninsured or lacks coverage for EYLEA® (aflibercept) Injection
  • Is a resident of the United States or its territories or possessions
  • Demonstrates financial need
    —Supporting documentation required
Notify you of patient’s eligibility and, if approved, will:
  • Coordinate shipment of EYLEA to your practice
  • Send you a confirmation letter regarding patient enrollment, along with a Product Request Form (PRF) for future Patient Assistance Program shipments
    • Proactively send the PRF a week before the next scheduled injection to coordinate shipment
Questions about applying for coverage, eligibility criteria, or denied claims?
Call EYLEA4U® at 1-855-EYLEA4U (1-855-395-3248), Option 4,
Monday–Friday 9AM to 8PM Eastern Time.
IMPORTANT SAFETY INFORMATION
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  • EYLEA® (aflibercept) Injection is contraindicated in patients with ocular or periocular infections, active intraocular inflammation, or known hypersensitivity to aflibercept or to any of the excipients in EYLEA.
  • Intravitreal injections, including those with EYLEA, have been associated with endophthalmitis and retinal detachments. Proper aseptic injection technique must always be used when administering EYLEA. Patients should be instructed to report any symptoms suggestive of endophthalmitis or retinal detachment without delay and should be managed appropriately. Intraocular inflammation has been reported with the use of EYLEA.
  • Acute increases in intraocular pressure have been seen within 60 minutes of intravitreal injection, including with EYLEA. Sustained increases in intraocular pressure have also been reported after repeated intravitreal dosing with VEGF inhibitors. Intraocular pressure and the perfusion of the optic nerve head should be monitored and managed appropriately.
  • There is a potential risk of arterial thromboembolic events (ATEs) following intravitreal use of VEGF inhibitors, including EYLEA. ATEs are defined as nonfatal stroke, nonfatal myocardial infarction, or vascular death (including deaths of unknown cause). The incidence of reported thromboembolic events in wet AMD studies during the first year was 1.8% (32 out of 1824) in the combined group of patients treated with EYLEA. The incidence in the DME studies from baseline to week 52 was 3.3% (19 out of 578) in the combined group of patients treated with EYLEA compared with 2.8% (8 out of 287) in the control group; from baseline to week 100, the incidence was 6.4% (37 out of 578) in the combined group of patients treated with EYLEA compared with 4.2% (12 out of 287) in the control group. There were no reported thromboembolic events in the patients treated with EYLEA in the first six months of the RVO studies.
  • Serious adverse reactions related to the injection procedure have occurred in <0.1% of intravitreal injections with EYLEA including endophthalmitis and retinal detachment.
  • The most common adverse reactions (≥5%) reported in patients receiving EYLEA were conjunctival hemorrhage, eye pain, cataract, vitreous floaters, intraocular pressure increased, and vitreous detachment.
IMPORTANT PRESCRIBING INFORMATION

EYLEA® (aflibercept) Injection is indicated for the treatment of patients with

  • Neovascular (Wet) Age-related Macular Degeneration (AMD): The recommended dose is 2 mg administered by intravitreal injection every 4 weeks (monthly) for the first 12 weeks (3 months), followed by 2 mg once every 8 weeks (2 months). Although EYLEA may be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated in most patients when EYLEA was dosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 12 weeks (3 months).
  • Macular Edema following Retinal Vein Occlusion (RVO): The recommended dose is 2 mg administered by intravitreal injection every 4 weeks (monthly).
  • Diabetic Macular Edema (DME) and Diabetic Retinopathy (DR) in Patients with DME: The recommended dose is 2 mg administered by intravitreal injection every 4 weeks (monthly) for the first 5 injections, followed by 2 mg once every 8 weeks (2 months). Although EYLEA may be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated in most patients when EYLEA was dosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 20 weeks (5 months).

Please see the full Prescribing Information for EYLEA.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

The information provided in this site is intended only for healthcare professionals in the United States. The products discussed herein may have different product labeling in different countries.

The EYLEA4U® e-Portal

Call 1-855-EYLEA4U (1-855-395-3248), Monday–Friday 9 AM–8 PM Eastern Time.
Getting In Touch

EYLEA and EYLEA4U are registered trademarks of Regeneron Pharmaceuticals, Inc.

777 Old Saw Mill River Road, Tarrytown, NY 10591
US-LEA-13837

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