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Eisai Banzel Patient Assistance Program
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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)430-9818
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Eligibility
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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
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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. |
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Required
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Medically appropriate condition/diagnosis is required. |
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Supply
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Amount of medication varies. Refill process not applicable. Refill limit varies. New application must be completed yearly. |
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Ship To
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Mediation is shipped to Patient's house. |
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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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| Banzel oral suspension |
| Banzel 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 Banzel Patient Assistance Program |
(Requires Acrobat Reader) 
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