iDose TR Copay Assistance Program

The iDose TR Copay Assistance Program may help eligible commercially insured patients with out-of-pocket costs for iDose TR and, where allowed by law, eligible procedure costs directly related to its administration.

Need help?
For support: 1-844-694-3673
Monday-Friday, 8:00 AM-8:00 PM ET

You can enroll in the iDose TR Copay Assistance Program in one of two ways:

Option 1: Start enrollment yourself
You may complete the patient sections of the iDose TR Copay Enrollment Form and fax the completed form to the program.

Option 2: Ask your healthcare provider’s office to help
Your healthcare provider’s office can help complete the iDose TR Copay Enrollment Form with you and fax the completed form to the program on your behalf.

In either case, you will need to review and sign the patient sections of the form before it can be submitted.

You will need to provide:

• Insurance information
• A copy of the front and back of your insurance card
• A signed patient authorization
• Additional information if requested by the program

Your healthcare provider will also need to complete and sign the provider section of the form.

You or your healthcare provider can use this form to start the enrollment process in the iDose TR Copay Assistance Program.

Download the iDose TR Copay Enrollment Form

After enrollment is submitted, the program reviews the information provided, confirms eligibility, and may conduct benefit-related support, as applicable.

The program may contact you or your healthcare provider’s office if additional information is needed.

Treatment occurs through your provider’s normal clinical and billing process. Copay support is addressed after treatment and claim processing, based on the required documentation submitted.

If you paid an eligible out-of-pocket cost, you may request reimbursement directly.

To request reimbursement:

• Complete and sign the Patient Reimbursement Form
• Include required supporting documentation
• Fax the completed form and documentation to 1-844-iDoseFX (1-844-436-7339)
• After review and approval, eligible reimbursement is issued by check. To avoid delays in getting your reimbursement, tell the Program right away if your address changes

Use this form if you paid an eligible out-of-pocket cost and are requesting reimbursement directly. Fax the complete reimbursement form to the iDose TR Copay Assistance Program at 1-844-iDoseFX (1-844-436-7339). Before you send in your request, please make sure you are already enrolled in the iDose TR Copay Assistance Program, reimbursement cannot be issued unless you are enrolled.

Download Patient Reimbursement Form

The following documents must be provided to be eligible for copay assistance:

• Explanation of Benefits, also called an EOB: a document from your insurance company after a medical visit that explains what was covered and what you may owe
• Itemized bill: a detailed bill from your provider that shows the services you received and their costs
• Proof of payment: a receipt or other documentation showing that you paid the provider out-of-pocket, if you already paid
• Date of service or treatment details: the date you received care or other details about your treatment

Review this checklist for more information on what documents you need to submit with your copay reimbursement request.

Download Patient Reimbursement Checklist

For support, call:
1-844-MyiDose (1-844-694-3673)
Monday-Friday, 8:00 AM-8:00 PM ET

After your reimbursement request is submitted, the iDose TR Copay Assistance Program will review the form and the supporting documentation to evaluate whether additional information is needed.

If you are eligible, a reimbursement check will be processed within 2-3 weeks of receipt of your completed application.

Providers can help enroll eligible commercially insured patients in the iDose TR Copay Assistance Program by completing the iDose TR Copay Enrollment Form together with the patient and faxing the completed form to the Program.

Before submitting the form, confirm that the patient has completed the required patient sections, provided insurance information, and signed the patient authorization.

If requesting reimbursement directly and the patient has not paid the eligible out-of-pocket, the provider section must also be completed and signed.

Use this form to enroll your eligible patients in the iDose TR Copay Assistance Program.

Download the iDose TR Copay Enrollment Form

Fax completed enrollment forms to:
1-844-iDoseFx (1-844-436-7339)

For support, call:
1-844-MyiDose (1-844-694-3673)
Monday-Friday, 8:00 AM-8:00 PM ET

Providers may request reimbursement through available provider-driven pathways. Before reimbursement can be issued to a provider, the provider office and/or site of care must first register with IQVIA.

Step 1: Register with IQVIA
Provider offices and sites of care/ASCs must register with IQVIA before submitting provider reimbursement requests or enabling electronic copay billing.

If the provider office and site of care/ASC are separate billing or taxable entities, each entity must complete the appropriate registration form.

Download IQVIA Registration Form for Provider Offices

Download IQVIA Registration Form for Sites of Care / ASCs

Step 2: Choose a provider reimbursement pathway
After registration is complete, providers may request reimbursement through one of the following pathways.

Option 1: Electronic Data Interchange (EDI)
Providers who want to submit copay claims electronically through their existing billing system may complete EDI setup.

Through this pathway:

• The provider and/or site of care is registered with IQVIA
• EDI setup is completed through the provider’s existing claims system or clearinghouse
• IQVIA is added as a secondary payer
• The copay claim is submitted electronically after primary insurance adjudication
• If approved, eligible reimbursement is issued to the provider

Download iDose TR Copay Assistance Program EDI Setup Guide

Option 2: Provider fax-enabled reimbursement
Providers who are not using EDI may submit a provider reimbursement request by fax.

Through this pathway:

• The provider or site of care is registered with IQVIA
• The provider or site of care completes the Provider Reimbursement Form
• Required supporting documentation is submitted by fax, including the patient’s Explanation of Benefits, also called an EOB
• If approved, eligible reimbursement is issued to the provider

Download Provider Reimbursement Form

Eligible reimbursement will be issued based on the reimbursement pathway used. The provider may receive reimbursement via ETF or check, depending on setup. If you are eligible, a reimbursement will be processed within 2-3 weeks of receipt of your completed application.

The program may contact the provider’s office or the patient if additional information is needed to complete the review. You can contact the iDose TR Copay Assistance Program for alternative reimbursement methods, if needed.