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Patient Assistance Information


Phone : (844)438-5469
Fax: (844)364-2424
> Insurance status will be considered on a case by case basis. Patients must meet income requirements that have not been disclosed, have a medically appropriate condition/diagnosis and be a US resident.
Who Can Apply
> Anyone interested can call to have an application faxed, emailed or mailed. The application can also be downloaded.
> Doctors and patients must each complete a section of the application and sign. The application can then be faxed or mailed.
> Not specified
Ship To
> Patient's home, unless otherwise noted
> This program also provides copay assistance.
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.
Hetlioz capsule
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
Download printable Form
(Requires Acrobat Reader