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Patient Assistance Information

 
1 Program for Banzel tablet
 
 
Eisai Banzel Patient Assistance Program

c/o Rx Outreach
PO Box 66536
St. Louis, MO 63166
Phone : (888)796-1234
Fax: (888)430-9818
Eligibility
> This program is intended for patients that are uninsured, have denied coverage or are awaiting public assistance determination. Medicare Part D patients are not eligible for this program. Income must be at or below 300% of FPL. Patient must reside in United States or Puerto Rico
Who Can Apply
> Call to have application faxed or mailed. Application can be faxed or mailed back to company. Doctor must complete application and sign. Patient must complete application, sign, attach a copy of proof of income, attach front and back copy of insurance card. Doctor & patient will be notified of decision.
Required
> Medically appropriate condition/diagnosis is required.
Supply
> Amount of medication varies. Refill process not applicable. Refill limit varies. New application must be completed yearly.
Ship To
> Mediation is shipped to Patient's house.
Note
>
 
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.
 
Banzel tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Eisai Banzel Patient Assistance Program
(Requires Acrobat Reader