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SeaGen Secure Patient Assistance Program
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21823 30th Dr. SE
Brothell, WA 98021
Phone
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855-473-2436
Ext 1
Fax:
855-557-2480
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Eligibility
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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
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Patients or healthcare providers can call to have an application faxed or emailed. An application can also be downloaded. |
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Required
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Doctors must complete a section of the application. Patients must complete a section of the application and attach required documents. |
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Supply
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Varies |
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Ship To
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Clinic or hospital |
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Note
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* 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. |
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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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| Adcetris injection |
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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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