The LEQEMBI Copay Assistance Program is sponsored by Eisai. This program
is available to help eligible commercially insured patients with their
Patients with a state or federally funded insurance, such as
Medicare Part B
or Medicaid, are not eligible for the program.
Copay Assistance Program terms and conditions
Patient must be prescribed LEQEMBI for an FDA-approved indication. Patient
must have private, commercial health insurance that provides coverage for
LEQEMBI. The offer is not valid for patients enrolled in state and federal
healthcare programs, including Medicare, Medicaid, Medigap, VA, DoD, or
TRICARE. The offer is not valid for uninsured or self-paying patients, or for
LEQEMBI treatments reimbursed in full by any third-party payer. Patient must
be 18 years or older. Patient must be a resident of, and product must be
administered in, the United States or Puerto Rico.
The benefit available under the LEQEMBI Copay Assistance Program is limited
to patient's out-of-pocket cost for LEQEMBI, as indicated in documentation
provided by the patient's health insurance provider, including a CMS-1500 or
UB-04 Form AND an insurance explanation of benefits (EOB) with itemized
charges which include the billing code for LEQEMBI. Eligible patients who
participate in the Program may pay as little as $0 out-of-pocket per date of
treatment. Eisai Inc. will pay up to $10,000 per calendar year toward an
eligible patient's out-of-pocket costs for LEQEMBI, including deductibles,
copays and coinsurances. Depending on the patient's insurance plan, patient
could have additional financial liability for any amounts over Eisai's maximum
benefit. The offer is not valid for any other out-of-pocket costs, including
medical administration charges. Supporting documentation must be
submitted to the LEQEMBI Copay Assistance Program within 365 days of the
date of treatment or the request will be rejected. In order to be eligible for
reimbursement under LEQEMBI Copay Assistance Program, claims for
LEQEMBI must be submitted by provider to patient's private health insurance
separately from other services and products. Additional instructions regarding
required documentation in support of each claim will be provided by the
program following confirmation of eligibility and enrollment. The LEQEMBI
Copay Assistance Program will process eligible claims for patient out-of-
pocket costs for LEQEMBI incurred for product administered up to 180 days
prior to the date the patient is enrolled in the program.
Upon enrollment in the program, each patient will be issued a 16-digit virtual
debit card. By enrolling in this program, the patient is providing consent for
the LEQEMBI Copay Assistance Program to provide payment information for
any approved claims, in the form of the 16-digit virtual debit card number,
directly to the provider or alternate site of care identified on this enrollment
form to be applied directly to the patient's out-of-pocket costs for LEQEMBI.
By enrolling in the program and accepting payment, provider agrees to put
the value of the patient LEQEMBI Copay Assistance Program directly toward
the patient's out-of-pocket costs for LEQEMBI only. If provider has already
received payment from the patient for the patient's out-of-pocket cost for
LEQEMBI covered by the program, provider agrees to refund the amounts
received back to the patient.
Patient and provider agree not to seek reimbursement for any or all of the
benefit received by the patient through the LEQEMBI Copay Assistance
Program. Patients and providers are responsible for complying with all
requirements to disclose to insurance carriers and third-party payers the
benefit received from the LEQEMBI Copay Assistance Program. The offer may
not be combined with any other discount, coupon, free trial or offer. Federal
law prohibits the selling, purchasing, trading, or counterfeiting of this offer.
Void outside the USA and where prohibited by law. Eisai Inc. reserves the right
to rescind, revoke, or amend this offer at any time without notice. The value
of this offer is not contingent on any prior or future purchases. This offer is
solely intended to provide savings on the purchase of LEQEMBI. This offer
may not be accepted by all providers or alternate sites of care. The LEQEMBI
Copay Assistance Program is not an insurance program. No membership fees.
This offer will expire 12/31/2023.