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Patient Assistance Information

 
2 Programs for Adcetris injection
 
 
SeaGen Secure Commercial Co-insurance Assistance Program

21823 30th Dr. SE
Brothel, WA 98021
Phone : 855-473-2436 Ext 1
Fax: 855-557-2480
Eligibility
> Patients may have private or commercial insurance coverage but may not be a participant in federal or state-funded benefits programs. Gross family household income must be at or less than $125,000 per year. Patients must also reside permanently in the US or US territories.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. The application can also be completed online or downloaded.
Required
> Patients must inform their doctor that they are in need. The doctors office must call.
Supply
> Not applicable
Ship To
> Doctor's office
Note
> Income and residency documentation required.
 
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.
 
Adcetris injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader
 
 
SeaGen Secure Patient Assistance Program

21823 30th Dr. SE
Brothell, WA 98021
Phone : 855-473-2436 Ext 1
Fax: 855-557-2480
Eligibility
> Patients must be uninsured or under insured, must have a gross family household income at or less than $125,000, have HL or NHL, and must reside permanently in the US or US territories.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or emailed. An application can also be downloaded.
Required
> Doctors must complete a section of the application. Patients must complete a section of the application and attach required documents.
Supply
> Varies
Ship To
> Clinic or hospital
Note
> * If approved, One Q3W cycle will be shipped to the Provider for IV administration. Patient can be on any line of therapy, any dosing schedule, and be pre or post Autologous Stem Cell Transplant. Insurance benefits, claims assistance and/or other reimbursement help is offered. Income and residency documentation required.
 
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.
 
Adcetris injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader