Downloadable resources to assist you with reimbursement processes for BANZEL®.
The BANZEL® Eisai Assistance Program Benefit Investigation Form initiates a benefits investigation to provide information on patient insurance coverage and coverage restrictions. This may include any Prior Authorization requirements set by their insurance company. The completed benefit investigation form, insurance information, financial documentation, signature of the prescribing healthcare professional, and patient's signature are required for the form to be considered complete.
The sample appeal letter is a template of letter that could be used to appeal for coverage of BANZEL® with a payor.
The Sample Letter of Medical Necessity is a template of a letter that could be used to provide a payor additional information about the need for a patient to use BANZEL®.
This application is used to determine whether patients may be eligible for the BANZEL® Rx Outreach Medication Program. This form has been annotated to include specific information as it relates to BANZEL®.
These foundations offer financial and other assistance (education, counseling, support groups, etc.) to patients.
If you are pregnant, call 1-888-233-2334 to enroll in the North American Antiepileptic Drug Pregnancy Registry.
The LGS Foundation's mission is to improve the lives of individuals affected by Lennox-Gastaut Syndrome through research, programs, and education.
Eisai cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payors following the receipt of claims. For additional information, customers should consult with their payors for all relevant coding, reimbursement, and coverage requirements. It is the sole responsibility of the provider to select the proper code and ensure the accuracy of all claims used in seeking reimbursement. All services must be medically appropriate and properly supported in the patient medical record.
BANZEL is indicated for adjunctive treatment of seizures associated with Lennox-Gastaut Syndrome (LGS) in pediatric patients 1 year of age and older, and in adults.
For more information about BANZEL® please see Prescribing Information.
BANZEL® is available by prescription only.
This information is intended for use by our healthcare professionals in the United States only. Eisai Inc. recognizes the Internet is a global communications medium; however, laws, regulatory requirements and medical practices for pharmaceutical products vary from country to country. The Prescribing Information included here is not appropriate for use outside the United States.
This site contains information about products that may have different product labeling in different countries. This site is published by Eisai Inc.