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The LEQEMBI Copay Assistance Program is sponsored by Eisai. This program is available to help eligible commercially insured patients with their medication cost. Patients with a state or federally funded insurance, such as Medicare Part B or Medicaid, are not eligible for the program.

LEQEMBI 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.

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. Eligible patients who participate in the Program may pay as little as $0 out-of-pocket per date of treatment. Depending on the patient’s insurance plan, patient could have additional financial liability for any amount over Eisai’s maximum benefit. The offer is not valid for any other out-of-pocket costs, including medical administration charges. 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. For patients prescribed LEQEMBI infusions, 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 Infusions only. Patient and provider/pharmacy agree not to seek reimbursement for any or all of the benefit received by the patient through the LEQEMBI Copay Assistance Program and 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, pharmacies or alternate sites of care. The LEQEMBI Copay Assistance Program is not an insurance program. There will be no membership fees.

Additional Copay Assistance Program terms and conditions that apply to the LEQEMBI Infusion Copay Assistance Program ONLY: In order to be eligible for reimbursement under the LEQEMBI Copay Assistance Program, claims for LEQEMBI infusions must be submitted by provider to patient’s private health insurance separately from other services and products. Supporting documentation, including a CMS-1500 or UB-04 form and an insurance explanation of benefits (EOB) with itemized charges that include the billing code for LEQEMBI, must be submitted to the LEQEMBI Copay Assistance Program within 365 days of the date of treatment or the request will be rejected.

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 infusions. If provider has already received payment from the patient for the patient’s out-of-pocket cost for LEQEMBI infusions covered by the program, provider agrees to refund the amounts received back to the patient.

The LEQEMBI Infusion Temporary Supply Program (“TSP”) 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.

LEQEMBI Infusion Temporary Supply Program terms and conditions

Patient must have a valid prescription for LEQEMBI Infusion for an FDA-approved indication. Patient must have private, commercial insurance that provides coverage for drugs through a medical benefit. The LEQEMBI Infusion TSP is not available for uninsured patients or patients enrolled in state and federal healthcare programs, including Medicare, Medicaid, Medigap, VA, DoD, or TRICARE. 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. Patient must meet the financial eligibility criteria for enrollment in the Patient Assistance Program for LEQEMBI in order to be eligible for the TSP.

In order to be eligible for the TSP, the patient must be new to LEQEMBI infusion therapy and must be awaiting a final coverage determination from their insurance provider for five or more business days and the patient’s provider has submitted a first-level appeal of the prior authorization denial. If an enrolled patient’s appeal is subsequently approved, patient will no longer be eligible to receive temporary supply of LEQEMBI Infusion. 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 until a final coverage determination is made. Limit of one enrollment (up to 75-day 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. Provider further agrees that LEQEMBI provided under the TSP may not be sold, traded, bartered, transferred, or returned for credit. LEQEMBI provided under the TSP must be maintained separately from commercial inventory. If the enrolled patient is no longer on therapy or otherwise cannot use the temporary supply of LEQEMBI, provider agrees to promptly contact Eisai Patient Support to arrange for product return or disposal.

No patient, pharmacy, payor, or other third-party may be billed for the temporary supply of LEQEMBI. Patients and providers must not submit any claim for reimbursement for product dispensed pursuant to the TSP to any third-party payor, including Medicare, Medicaid, or any other federal or state health care program. Patient cannot seek to have any part of the value of the free product received through the TSP count towards any applicable out-of-pocket spending calculations for drugs (e.g., deductible or out-of-pocket cap). The free LEQEMBI provided under the TSP is not contingent on any past or future purchases of any product, under the patient’s insurance benefit or otherwise. Eligibility determinations are made without regard to patient’s commercial insurance provider, choice of physician or infusion provider. Patients are free to change physicians or infusion providers at any time. The TSP is not a health insurance, financial support, or cost savings program. Limitations may apply. Eisai reserves the right to rescind, revoke, or amend the TSP at any time without notice. TSP is available to LEQEMBI Infusion patients only. Additional terms and conditions and eligibility criteria apply. Contact the LEQEMBI Companion program for additional information.

The LEQEMBI Patient Assistance Program is for patients who need help paying for LEQEMBI. This program provides LEQEMBI at no cost to uninsured and financially burdened patients who meet the program eligibility criteria.

Patient Assistance Program terms and conditions

The Patient Assistance Program (''Program'') provides free drug for eligible patients who meet financial need and insurance coverage criteria. Patients must have a valid prescription for LEQEMBI for an FDA-approved indication. Patient must be either uninsured or insured but without insurance coverage for LEQEMBI (i.e., the insurer must have denied a first-level appeal of an initial coverage denial) or without enough coverage to pay for LEQEMBI. Patient must have a household income equal to or less than 300 percent of the Federal Poverty Level. 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. Commercially insured patients and Federal health care program beneficiaries who qualify for the Program are enrolled for the entire calendar year. Uninsured patients who qualify for the Program are enrolled for a rolling 12-month period. During the Program enrollment period, patients must receive all LEQEMBI doses through the Program only. Patients cannot be administered commercial units of LEQEMBI, and neither patients nor providers may submit claims for commercial units of LEQEMBI, during the Program enrollment period. All patients must re-enroll at the end of their respective Program approval period to ensure they continue to meet the Program's eligibility criteria. Eisai reserves the right to reassess eligibility for patients with commercial insurance during the enrollment period.

For LEQEMBI Infusion, the Program will ship each dose of LEQEMBI directly to the provider or infusion center identified in patient’s enrollment form. Quantities of Product shipped are limited to the number of vials the prescribing physician confirmed in writing are needed and clinically appropriate for the designated patient for a one-month supply of the Product. By accepting shipment, provider agrees to administer the free supply of LEQEMBI only to the enrolled patient and to discard unused amounts in open vials.

For LEQEMBI IQLIK™, the Program will ship LEQEMBI directly to the patient's home address entered on the enrollment form unless otherwise indicated by the prescriber.

Product provided through the Program may not be sold, traded, bartered, transferred, or returned for credit. LEQEMBI provided under this Program must be maintained separately from commercial inventory. If the enrolled patient is no longer on therapy or otherwise cannot use the free supply of LEQEMBI, provider or patient agrees to promptly contact the LEQEMBI Companion program to arrange for product return or destruction. If provider fails to meet any Program requirements, the Program will cease sending any additional Program product to the provider until the provider comes into compliance.

No patient, pharmacy, payor, or other third-party may be billed for the free drug provided pursuant to the Program. Patients and providers must not submit any claim for reimbursement for product pursuant to this Program to any third-party payor, including Medicare, Medicaid, or any other federal or state health care program. Patient cannot apply the value of the free product received through this Program toward any insurance benefit out-of-pocket spending calculations such as Medicare Part D True Out-of-Pocket Costs (TrOOP). The free LEQEMBI provided under the Program is not contingent on any past or future purchases of any product, under the patient's insurance benefit or otherwise. Eligibility determinations are made without regard to patient's insurance provider (if any), choice of physician or infusion provider. Patients are free to change physicians or infusion providers at any time. The Program is not health insurance. Limitations may apply. Eisai reserves the right to rescind, revoke, or amend this Program at any time without notice. Additional terms and eligibility criteria apply. Contact the LEQEMBI Companion program for additional information.