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Patient Assistance Information

 
1 Program for Halaven injection
 
 
Eisai Assistance Program

PO Box 29231
Phoenix, AZ 85038
Phone : (866)613-4724
Fax: (866)573-4724
Eligibility
> Insurance requirements for this program are determined case by case. Medicare Part D eligibility not specified. Income requirements for this program have not been disclosed. Must be US resident.
Who Can Apply
> Call for faxed application or download from website. Patient and Doctor are notified of acceptance within 24-48hrs.
Required
> Doctors must complete and sign the application. Patient must complete application, sign and attach proof of income and any insurance information.
Supply
> Amount of medication varies. Doctor/Doctor's office must contact company for refills. Refill limit not specified. New application must be completed yearly.
Ship To
> Medication is shipped to Patient or Doctor's office in 1-3 business days.
Note
> Eligibility determined on a case-by-case basis. Insurance benefits, claims assistance and/or other reimbursement help is offered. If a patient has insurance and the medication is not covered, then they may still be eligible for some type of assistance. Contact program for Spanish application.
 
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.
 
Halaven injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Eisai Assistance Program
(Requires Acrobat Reader