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Eisai Assistance Program (Belviq)
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c/o Rx Outreach
PO Box 66536
St. Louis, MO 63166
Phone
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(888)796-1234
Fax:
(888)875-6591
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Eligibility
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This program is intended for patients that may or may not have insurance. Medicare Part D patients are eligible for this program. Income must be at or below 150% of FPL. Must reside in the US, Puerto Rico or the USVI |
| Who Can Apply
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Call for application to be faxed or mailed. May also download application from website or apply online. Doctor gives application to patient, Patient completes and signs application. Medications sent if accepted. If denied patient and doctor notified, usually within the same day. |
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Required
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Supply
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Amount varies. Company contacts Patient to arrange refills. Refills limited by manufacturer's guidelines. New application must be completed yearly. |
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Ship To
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Medication will be shipped to Doctor's office or Patient's home. |
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Note
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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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| Belviq tablet |
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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 Eisai Assistance Program (Belviq) |
(Requires Acrobat Reader) 
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Xubex Pharmaceutical Services
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PO Box 1244
Winter Park, FL 32790-1244
Phone
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866-699-8239
Fax:
407-671-7960
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Eligibility
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Patients may have insurance. There are no income limits for this program. Patients must be a US resident. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application. |
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Supply
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Varies |
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Ship To
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Either Doctor's office or Patient's home |
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Note
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No proof of income is required. Check the website for the exact price.
This service is not currently available in Montana. |
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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.
|
| Belviq tablet |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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