Leqembi Temporary Supply Program
Funded
About
The Leqembi Temporary Supply Program offers eligible, commercially insured patients awaiting a coverage decision a temporary supply of up to 75 days of Leqembi. This initiative aids patients by providing timely access to the medication while insurance determinations are pending, enhancing the continuity of care for those in need.
Insurance requirements: Commercially insured
Enrollment Forms
Enrollment Form
Program Requirements
•Valid only for residents in the US and Puerto Rico
•Must be 18 years of age or older
•Enrollment Required: Yes
•Coverage Required: No
•Needs Based: No
•Activation Required: No
Program Details
•Provides a temporary free supply of up to 75 days of LEQEMBI for eligible, commercially insured patients awaiting a coverage determination from their insurance provider for five or more business days
•Must have a valid prescription
•Note: The Temporary Supply Program (TSP) will ship each treatment of LEQEMBI directly to the provider or alternate site of care identified on this enrollment form; enrolled patients will be evaluated for continued TSP eligibility prior to each shipment
•In order for patient to continue to be eligible for the TSP, the patient’s provider must agree to appropriately pursue insurance coverage for the patient, including filing a firstlevel appeal of an initial coverage denial, if appropriate, until a final coverage determination is made
•Limitations may apply
•Limit of one enrollment (up to 75day supply while coverage is pending) per patient per lifetime
•The TSP will ship each treatment of LEQEMBI directly to the provider or alternate site of care identified on this enrollment form; enrolled patients will be evaluated for continued TSP eligibility prior to each shipment
•By accepting shipment, provider agrees to administer the temporary supply of LEQEMBI only to the enrolled patient named in the materials accompanying the shipment and to discard unused amounts in open vials. LEQEMBI provided under this Program must be maintained separately from commercial inventory
•For more information, contact the Eisai Patient Support Program at 18334537362
Enrollment Forms
Enrollment Form