The Enrollment Form
Allows EYLEA4U to verify insurance coverage and determine program eligibility based on the support requested. The following support is available:
- Copay Assistance
- Claims Assistance
- Appeals Support
- Prior Authorization (PA) Assistance
- Patient Assistance Program (PAP)
Submit the completed form by fax to 1-888-335-3264 or complete electronically via the EYLEA4U e-Portal*Visit the portal
*A completed and patient-signed form must be retained on file at the office for submissions entered via the e-Portal.
We have one-on-one reimbursement solutions and are here to help you through the entire reimbursement process
In addition to the BI, EYLEA4U Reimbursement Specialists can help with the following:
- Address questions on claims preparation
- Review the status of an EYLEA claim with the patient's insurer
- Provide information for resolving underpaid or denied claims or PAs for EYLEA
- Explain the insurer's appeals process
Visit this helpful library to find enrollment forms, sample appeal letters, and more.