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Program Details

EISAI, INC.
Eisai Assistance Program - Halaven
Targretin Gel 1% (bexarotene)
 
CONTACT INFO
Address:
,
Phone: 1-866-613-4724 Provider Phone:
Fax: Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Applications are reviewed on a case-by-case basis.
  • Patients who have insurance, but medication is not covered might still be eligible for this program.
  • Program also provides co-pay assistance.
    		•
    Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Physician License #
    Required:    		 DEA
    NPI
    Facility License number
    Prescriber Signature
    Allowed:    		 Physician
    Application may be
    faxed:    		 Yes
    Eligibility determination
    letter sent:    		 Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Not Published
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Physician's office must contact the program
    Other Information:

    Last Updated: 04/23/2024

    		  

     

     


    Application Forms
    & Instructions
    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Insurance Verification Form


    Document Halaven $0 Co-pay Enrollment Form

     

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