Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
Scroll down to see them all.
 

Eisai Assistance Program (Aloxi & Halaven)

This program provides brand name medications at no or low cost

Provided by: Eisai, Inc.

PO Box 29231
Phoenix, AZ 85038

TEL: 866-613-4724


FAX: 866-573-4724
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Eisai Assistance Program Enrollment Form

Eisai Assistance Program Insurance Verification Form

Eisai Assistance Halven $0 Co-Pay Program Enrollment Form

 

Medications

  • Aloxi injection (palonosetron)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Patient and Doctor notified of acceptance
Decision Timeframe Within 24-48 hours
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time 1-3 business days
Refill Process Doctor/Doctor's office must contact company
Limit Not specified
Re-application New application yearly
   

Additional Information

Eligibility determined on a case-by-case basis.

Insurance benefits, claims assistance and/or other reimbursement help is offered. If a patient has insurance and the medication is not covered, then they may still be eligible for some type of assistance.



Updated July 10, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • Aloxi injection (palonosetron)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated June 29, 2017