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Program Details

TAKEDA PHARMACEUTICALS U.S.A.
Entyvio Patient Assistance Program

Entyvio Injection (vedolizumab)
 
CONTACT INFO
Address: P.O. Box 13185
La Jolla, CA 92039
Phone: 1-855-368-9846 Provider Phone:
Fax: 1-877-488-6814 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must be uninsured or underinsured.
  • Patients with Medicare Part D may be eligible on case-by-case basis.
  • Income at or below: Single 500 % FPL
      Couple 500 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: No
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Physician License #
    Required:
    Both DEA and State
    NPI
    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: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Not Published
    Other Information:

    Last Updated: 02/26/2024

     

     

     


    Application Forms
    & Instructions

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


    DocumentForm (English)



     

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