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HetliozSolutions
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Phone
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(844)438-5469
Fax:
(844)364-2424
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Eligibility
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Insurance status will be considered on a case by case basis. Patients must meet income requirements that have not been disclosed, have a medically appropriate condition/diagnosis and be a US resident. |
| Who Can Apply
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Anyone interested can call to have an application faxed, emailed or mailed. The application can also be downloaded. |
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Required
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Doctors and patients must each complete a section of the application and sign. The application can then be faxed or mailed. |
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Supply
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Not specified |
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Ship To
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Patient's home, unless otherwise noted |
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Note
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This program also provides copay assistance. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Hetlioz capsule |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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