The DAYVIGO Patient Assistance Enrollment Form will assist in determining your eligibility for the Patient Assistance Program. Download the writeable PDF and fax to 844-737-3493. The enrollment form, insurance information, signature of the prescribing healthcare professional, and patient's signature are required. This form has been annotated to include specific information as it relates to DAYVIGO.
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.
DAYVIGO is a prescription medicine for adults age 18 years and older who have trouble falling or staying asleep (insomnia).
Do not take DAYVIGO if you fall asleep often at unexpected times (narcolepsy).DAYVIGO is a federally controlled substance because it can be abused or cause dependence.
Tell your healthcare provider about all of the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements.
The most common side effect of DAYVIGO is sleepiness.
These are not all of the possible side effects of DAYVIGO. Call your doctor for medical advice and if you have any new or worsening side effects.
Please read the Medication Guide for DAYVIGO and discuss it with your doctor
The information contained herein is provided for educational purposes only and is not intended to replace discussions with a healthcare professional. All decisions regarding patient care must be made with a healthcare professional, considering the unique characteristics of the patient.
This site is intended for residents of the United States only. Any products discussed herein may have different product labeling in different countries.
DAYVIGO™ is a trademark of Eisai R&D Management Co., Ltd. and is licensed to Eisai Inc.©2020 Eisai Inc.