Program Contact Info / Application Submission
Program	Visudyne Patient Assistance Program
Program Requirements
Details	Insurance card will be considered on a case by case basis Drivers license will be considered on a case by case basis Proof of Income required on a case by case basis Copy of most recent tax return such as 1040, 1099 accepted as proof of income Letter from Doctor stating zero income accepted as proof of income Form 4506T (If taxes were not filed) accepted as proof of income Most recent bank statements accepted as proof of income Most recent check/check stub copy accepted as proof of income Letter from employer accepted as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement accepted as proof of income Award Letter for Alimony/Child Support, Unemployment accepted as proof of income Notarized statement from patient stating zero income accepted as proof of income
Delivery of Medication
Delivery Options	Delivery directly to the patient will be considered on a case by case basis Delivery directly to the doctor will be considered on a case by case basis Shipment as a voucher card will be considered on a case by case basis
Application Process
New Applications	New applications will be considered on a case by case basis Patients applying directly to the program will be considered on a case by case basis Doctors applying directly to the program will be considered on a case by case basis Advocates applying directly to the program will be considered on a case by case basis Applying for a new application via phone will be considered on a case by case basis Applying for a new application via fax will be considered on a case by case basis Applying for a new application via mail will be considered on a case by case basis
Refills	Refills may be accepted on a case by case basis Patients may apply for refills on a case by case basis Doctors may apply for refills on a case by case basis Advocates may apply for refills on a case by case basis Applying for refills via phone will be considered on a case by case basis Applying for refills via fax will be considered on a case by case basis Applying for refills via mail will be considered on a case by case basis
Re-Applications	Re-Applications will be considered on a case by case basis Patients may apply for Re-Applications on a case by case basis Doctors may apply for Re-Applications on a case by case basis Advocates may apply for Re-Applications on a case by case basis Re-Applying via phone will be considered on a case by case basis Re-Applying via fax will be considered on a case by case basis Re-Applying via mail will be considered on a case by case basis
Appeals	Income Appeals accepted on a case by case basis Patients can apply for Income Appeals on a case by case basis Doctors can apply for Income Appeals on a case by case basis Advocates can apply for Income Appeals on a case by case basis Hardship Appeals accepted on a case by case basis Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can NOT apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail
Eligibility
Limitations	Patients may be eligible if LIS is denied on a case by case basis Patients may be eligible with existing prescription coverage on a case by case basis Patients may be eligible if prescription is not covered on a case by case basis Patients are NOT eligible if prescription coverage has been exhausted Patients are NOT eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted
Appeals
Conditions	Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied