Epioxa® Copay Assistance Program
Helping eligible patients lower their out-of-pocket costs for Epioxa.*
Download the Epioxa Copay Program BrochureOn this page
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.
Providers can enroll patients, submit copay program reimbursement requests, and access program resources through EpioxaCareConnect™.
*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 Assistance Program
Already using EpioxaCareConnect (ECC)?
Patients who have already been enrolled in EpioxaCareConnect may not require a separate copay enrollment. Eligible patients are will be evaluated for the Epioxa Copay Assistance Program through ECC.
If your patient has not been enrolled in EpioxaCareConnect, complete the Epioxa Copay Enrollment Form or enroll electronically through the HCP Portal.
Download the formSubmit a Copay Claim or Reimbursement Request
Providers may request copay support through the workflow that best fits their practice.
EDI: Submit the copay claim electronically as part of your billing workflow after primary insurance adjudication.
HCP Portal: Submit a reimbursement request with supporting documentation after patient responsibility has been determined.
Download EDI setup guide Download provider reimbursement form Download HCP Copay Claim GuideFind Forms and Resources
Access enrollment forms, reimbursement forms, EDI setup resources, educational materials, and claim submission guides.
Jump to ResourcesHow it Works
The Epioxa Copay Assistance Program fits into your patient’s keratoconus treatment journey like this:
1
Enroll
The Epioxa Copay Assistance Program fits into your patient’s keratoconus treatment journey like this:
If the patient has already been enrolled and consented in Epioxa CareConnect, no separate copay enrollment may be needed
If the patient has not yet been enrolled, complete the Epioxa Copay Enrollment Form or enroll the patient electronically through the HCP Portal
2
Provide Epioxa Treatment
Administer Epioxa according to your standard clinical workflows.
Depending on office policies and patient financial responsibility, practices may collect applicable patient out-of-pocket costs at the time of service or after claim adjudication.
3
Submit a Copay Claim or Reimbursement Request, if needed
If eligible patient responsibility remains after insurance adjudication, provider reimbursement may be requested through one of two pathways:
EDI Submission: Submit the copay claim electronically through your existing billing workflow.
HCP Portal Submission: Submit a reimbursement request through the HCP Portal with supporting documentation after patient responsibility is available.
4
Reimbursement Issued
If the request is approved, reimbursement may be issued:
To the you, the provider, via EDI, ACH, or check, depending on submission pathway and office workflow.
To the patient when the patient has already paid an eligible out-of-pocket expense and submits a copay reimbursement request directly.
For an overview of the program
Download the Epioxa Copay Assistance Program BrochureHow to enroll your patients
To participate in the Epioxa Copay Assistance Program, you must first be enrolled. If yes, no further action is required. Patients enrolled and consented in EpioxaCareConnect will be evaluated for eligibility for the Epioxa Copay Assistance Program
Has the Patient Already Been Enrolled in EpioxaCareConnect?
If yes, no further action is required. Patients enrolled and consented in EpioxaCareConnect will be evaluated for eligibility for the Epioxa Copay Assistance Program. If the patient has been enrolled, the Program will share the patient’s unique copay ID with your office to support future copay reimbursement requests, as applicable.
Patient Not Yet Enrolled?
Option 1: Enroll the patient in EpioxaCareConnect via the Provider Portal or by faxing the EpioxaCareConnect Patient Enrollment Form.
Option 2: Complete the Epioxa Copay Enrollment Form with your patient and submit via fax at 1-800-839-6276.
Download the formSubmit a Reimbursement Request
Providers may request reimbursement for eligible patient out-of-pocket responsibility through one of two pathways.
Option 1: Electronic Data Interchange (EDI)
Providers may submit a copay reimbursement request through the EDI process. EDI allows for electronic transmission of claims, reducing paperwork, minimizing errors, and speeding up processing times. This helps providers receive payments more quickly.
Through this pathway:
- The practice has first completed EDI registration and setup. The process allows providers to submit 837P copay claims and receive 835 ERA remittances electronically.
- The claim is submitted electronically through EDI
- After claim processing, eligible copay assistance reimbursement is issued to the provider
Use this guide for step-by-step instructions or contact EpioxaCareConnect at 1-855-5-EPIOXA (1-855-537-4692 option 1) for help registering your practice or facility.
Download the EDI setup guideOption 2: HCP Portal Submission
Providers may submit reimbursement requests directly through the HCP Portal by uploading:
- Remittance advice (RA)
- Patient Explanation of Benefits (EOB)
- Required supporting documentation
Approved claims are reimbursed via set preferred payment method (ACH or check).
Download the formWhat to Expect After Submitting a Reimbursement Request
After your reimbursement 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.
Call the Epioxa Copay Assistance Program at 1-855-5-EPIOXA (1-855-537-4692), Monday – Friday 8 am – 5 PM ET
Forms & Resources
Epioxa Copay Enrollment Form
Use this form to enroll patients in the Epioxa Copay Program if they are not already enrolled in EpioxaCareConnect.
Download the formEpioxa Copay Program Brochure
Share with patients to help explain program eligibility, enrollment, reimbursement options, available support.
Download the brochureEDI Registration Guide
Step-by-step instructions for establishing EDI submission and electronic remittance processing.
Download the guideHCP Copay Reimbursement Request Form
Use this form to submit a copay assistance claim request.
Download the formHCP Guide to Copay Claim Submission and Reimbursement
Use this guide to understand what documents may be needed and how to submit your reimbursement request.
Download the formFrequently Asked Questions (FAQs)
Eligibility, Terms, and Conditions
View eligibility terms and conditionsIMPORTANT SAFETY INFORMATION
Contraindications
EPIOXA® HD and EPIOXA® are contraindicated in patients with known hypersensitivity to benzalkonium chloride (BAC) or any ingredients in EPIOXA HD and EPIOXA. Epithelium-on corneal collagen cross-linking is contraindicated in aphakic and pseudophakic patients without a UV-blocking intraocular lens.
Warnings and Precautions
Corneal collagen cross-linking should be used with caution in patients with a history of herpetic keratitis due to the potential for reactivation of herpes keratitis.
Adverse Reactions
The most common adverse reaction was conjunctival hyperaemia (31%). Other adverse reactions, occurring in 5% to 25% of eyes included: corneal opacity (haze), photophobia, punctate keratitis, eye pain, eye irritation, increased lacrimation, corneal epithelium defect, eyelid oedema, corneal striae, visual acuity reduced, dry eye, and anterior chamber flare.
Dosage and Administration
EPIOXA HD and EPIOXA are for topical ophthalmic use. NOT for injection or intraocular use.
EPIOXA HD and EPIOXA are supplied in single-dose syringes. Discard opened syringes after use.
EPIOXA HD and EPIOXA are for use with the O2n System and Boost Goggles only.
Refer to the O2n System Operator’s Manual and Boost Goggles User Guide for device instructions.
INDICATIONS AND USAGE
EPIOXA® HD (riboflavin 5’-phosphate ophthalmic solution) 0.239% and EPIOXA® (riboflavin 5’-phosphate ophthalmic solution) 0.177% are photoenhancers indicated for use in epithelium-on corneal collagen cross-linking for the treatment of keratoconus in adults and pediatric patients aged 13 years and older, in conjunction with the O2n® System and the Boost Goggles®.
Please see full Prescribing Information for EPIOXA HD and EPIOXA at www.Epioxa.com.
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.