Eylea4U Enrollment Form - Web there are 2 ways to enroll in eylea4u. ¶ you will need to provide financial documentation to support this information. There is no income criteria for copay program enrollment.* Eylea4u commercial copay card program. For patients with commercial insurance (not funded through a government healthcare program), eylea4u may be able to help with some of the copay costs for eylea hd. Complete the enrollment form online via: Web health information on this form to reimbursement support programs such as eylea4u® for purposes of conducting an investigation of my patient’s health insurance coverage benefits for eylea® (aflibercept) injection. Web be enrolled in eylea4u ® 4. Show financial need (based on total annual household adjusted gross income) ¶ if approved, patients may be eligible for assistance for up to 1 year and must reapply annually. Web click on document links below to download forms.
Web health information on this form to reimbursement support programs such as eylea4u® for purposes of conducting an investigation of my patient’s health insurance coverage benefits for eylea® (aflibercept) injection. For patients with commercial insurance (not funded through a government healthcare program), eylea4u may be able to help with some of the copay costs for eylea hd. Eylea4u commercial copay card program. Web be enrolled in eylea4u ® 4. There is no income criteria for copay program enrollment.* Web there are 2 ways to enroll in eylea4u. Web click on document links below to download forms. Complete the enrollment form online via: Show financial need (based on total annual household adjusted gross income) ¶ if approved, patients may be eligible for assistance for up to 1 year and must reapply annually. ¶ you will need to provide financial documentation to support this information.