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Epioxa® Copay Assistance Program

Helping eligible patients lower their out-of-pocket costs for Epioxa.*

Download the Epioxa Copay Program Brochure
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Eligible patients may pay as little as

$0

out-of-pocket*

The Epioxa Copay Assistance Program may help eligible commercially insured patients reduce out-of-pocket costs associated with Epioxa treatment, including eligible costs for Epioxa and the cross-linking procedure.

Program benefits may apply to deductible, coinsurance, and copayment costs.

*Financial support is available for commercially insured eligible patients only. Additional restrictions apply. Subject to program .

Terms & Conditions

Epioxa Copay Assistance Program Terms and Conditions:

  • Patient eligibility requires enrollment in EpioxaCareConnect™ (ECC) and completion of a benefits investigation.
  • The Epioxa Copay Program (“Program”) is available exclusively to patients with commercial (private or non-governmental) insurance who have a valid prescription for an FDA-approved use of Epioxa.
  • Patients who use Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE, or any other federal or state government program (collectively, “Government Programs”) to pay for Epioxa or related administration services are not eligible.
  • The Program is also invalid if all costs can be fully reimbursed by commercial insurance or other assistance programs.
  • Under the Program, patients may still be required to pay a co-pay. Depending on individual insurance coverage, out-of-pocket expenses for Epioxa may be reduced to as little as $0 per calendar year. The exact out-of-pocket cost depends on the patient’s health insurance plan.
  • The Program helps cover the cost of Epioxa and, where allowed by law, may also assist with eligible procedure costs directly related to its administration. Program benefits cannot exceed the patient’s actual out-of-pocket expenses for Epioxa. This Program is not health insurance or a benefit plan; the patient’s non-governmental insurance remains the primary payer.
  • Once enrolled, the Program will honor claims for services rendered up to 180 days prior to the enrollment date. Claims must be submitted within 180 days of the date of service, unless otherwise specified.
  • Use of this Program must comply with all relevant health insurance requirements. Patients, pharmacies, physicians’ offices, and hospitals participating in the Program are responsible for reporting all Program benefits received, as required by insurers or the law.
  • Program benefits may not be sold, purchased, traded, or offered for sale.
  • The patient or their guardian must be at least 18 years old to receive assistance through the Program. The Program is valid only in the United States and U.S. Territories and is void where prohibited by law.
  • The Program’s value is intended solely for the benefit of the patient. Funds provided through the Program may only be used to reduce out-of-pocket costs for enrolled patients.
  • Patients must have commercial insurance and provide proof of financial responsibility for a portion of the drug and/or procedure cost, if applicable.
  • This offer cannot be combined with any other rebate, coupon, or similar offer for Epioxa.
  • Glaukos reserves the right at any time to delete, modify, or change the terms, benefits, and conditions without notice.

Get Started

Enroll in the Epioxa Copay Program

Your provider may have already 
enrolled you.

If you need to enroll, your provider’s office can help, or you can complete the Epioxa Copay Enrollment Form yourself.

If you are unsure whether you have already been enrolled, please contact the Epioxa Copay Assistance Program at 1-855-5-EPIOXA, and a team member will be happy to assist.

Download the form

Submit a Copay Assistance Claim Request

Already enrolled and submitting a copay assistance claim?

You may submit your Patient Reimbursement Form and supporting documents through the patient portal 
or by fax.

Download the form Download copay claim guide

Find Forms
and Resources

Find program materials, enrollment forms, reimbursement forms, and 
step-by-step instructions.

Jump to Resources

Call the Epioxa Copay Assistance Program
at 1-855-5-EPIOXA (1-855-537-4692),
Monday – Friday 8 am – 5 PM ET

 Visit the EpioxaCareConnect Patient Portal

How it Works

The Epioxa Copay Assistance Program fits into your keratoconus treatment journey like this:

1

Enroll

Enroll in the Epioxa Copay Program before, during, or after treatment.

If you are already enrolled in the Copay Program, no further action is needed.

Reminder: Copay reimbursement requests must be submitted within 180 days of the treatment date.

2

Receive your Epioxa Treatment

Your provider's office may ask you to pay your out-of-pocket cost for Epioxa and/or the cross-linking procedure.

3

Submit a Reimbursement Request, if needed

After treatment and insurance processing, you or your provider may submit a reimbursement request for eligible out-of-pocket expenses.

4

Know what to expect after you submit

Check: If you already paid your eligible 
out-of-pocket cost, reimbursement may be issued to you directly by check.

Valid reimbursement requests will be processed and you should expect reimbursement in 2-3 weeks.

For an overview of the program

Download the Epioxa Copay Assistance Program Brochure

How to enroll

To participate in the Epioxa Copay Program, you must first be enrolled.

Check your enrollment status

Your provider may have already enrolled you in EpioxaCareConnect. If you are not sure, contact EpioxaCareConnect or ask your provider’s office.

If you have been approved for copay assistance, please share your copay ID with your provider. This will help them submit for reimbursement on your behalf, if needed.

Enroll if needed

If you are not already enrolled, your provider’s office can help, or you can complete the Epioxa Copay Enrollment Form yourself.

Download the form

Complete and submit your completed Epioxa Copay Enrollment form

You may upload your completed form through the EpioxaCareConnect patient portal, or fax it to the program.

Visit the Patient Portal

Submit a Copay Assistance Claim Request

If you are already enrolled in the Epioxa Copay Assistance Program and have an eligible out-of-pocket cost, you may submit a copay assistance claim request.

Review the Guide to Copay Assistance Claim Requests and Reimbursement to learn more about how to submit a request

Patient Copay Reimbursement Request Form

Download the form

Guide to Copay Assistance Claim Requests and Reimbursement

Download the form

Alternatively, your provider may file a copay reimbursement request on your behalf. If this is the case, no action may be needed.

What to Expect After Submitting a Copay Assistance Claim Request

After your request is submitted, the Epioxa Copay Assistance Program will review your completed form and supporting documents.

If information is missing or cannot be verified, the program may contact you or your provider’s office.

How payment may be issued

If your request is approved, payment may be issued in one of two ways:

Check: If you already paid your eligible out-of-pocket cost, reimbursement may be issued to you directly by check. Processing times may vary based on the completeness of your submission, but should typically take 2-3 weeks from completion of your request.

Debit card (or other preferred payment method): If you have not already paid your healthcare provider, payment information may be provided to them through a preloaded virtual debit card, or their preferred payment method if otherwise denoted.

Call the Epioxa Copay Program at 1-855-5-EPIOXA (1-855-537-4692),
Monday – Friday 8 am – 5 PM ET

Forms and Resources

Epioxa Copay Enrollment Form

Use this form to enroll in the Epioxa Copay Program if your provider has not already enrolled you.

Download the form

Epioxa Copay Program Brochure

Learn more about the program, eligibility, enrollment, and reimbursement.

Download the brochure

Epioxa Copay Program Tearpad

Use this quick-start guide to enroll and get started in the Epioxa Copay Program.

Download the guide

Patient Copay Reimbursement Request Form

Use this form to submit a copay assistance claim request.

Download the form

Guide to Copay Claim Assistance Requests and Reimbursement

Use this guide to understand what documents may be needed and how to submit your copay claim request.

Download the guide

Frequently Asked Questions (FAQs)

Eligibility, Terms, and Conditions

View eligibility terms and conditions

IMPORTANT SAFETY INFORMATION

The most common side effects were red eye, haze, sensitivity to light, disruption of surface cells of the cornea, eye pain, eye irritation, watery eyes, swelling of eyelid, fine white lines in the cornea, reduced sharpness of vision, dry eye, and eye inflammation.

You should not have the EPIOXA® corneal collagen cross-linking procedure if you have a known hypersensitivity to any ingredients in the product, have had cataract surgery and either did not receive an artificial lens in your eye or received a non-UV blocking artificial lens, have a history of herpetic keratitis, or are pregnant.

If you have any additional questions, please contact your doctor. Please see full Prescribing Information for EPIOXA HD and EPIOXA.

You are encouraged to report all side effects to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. You may also call Glaukos at 1-888-404-1644.

APPROVED USES

The EPIOXA corneal collagen cross-linking procedure is performed by your eye doctor for the treatment of keratoconus. It does not require the removal of the corneal epithelium (outermost layer of the front of the eye). It consists of EPIOXA® HD (riboflavin 5′-phosphate ophthalmic solution) 0.239% and EPIOXA® (riboflavin 5′-phosphate ophthalmic solution) 0.177%, which are prescription eye drops used in combination with the O2n® System and Boost Goggles®.

The EPIOXA corneal collagen cross-linking procedure is for the treatment of keratoconus in adults and pediatric patients 13 years of age and older.