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Helpful Resources

Helpful Resources

Patient Enrollment Form

This form allows the network specialty pharmacy or Access Central Coordinator to determine coverage and assess eligibility for financial assistance programs. This form requires a patient’s or representative’s signature.

Access & Support Services Brochure

Sample Letter of Medical Necessity

Prior Authorization Checklist


VANFLYTA is only available through a limited distribution program under a Risk Evaluation and Mitigation Strategy (REMS) called the VANFLYTA REMS because of the serious risk of QT prolongation, torsades de pointes, and cardiac arrest.

Enroll today to prescribe VANFLYTA with a one-time training for the VANFLYTA REMS Program at

The completion and submission of coverage-related documentation are the responsibility of the patient and healthcare provider. Daiichi Sankyo, Inc. makes no representation or guarantee concerning coverage or reimbursement for any service or item. A completed Patient Enrollment Form includes signatures from both the physician and the patient. Before submitting, please ensure all required information is provided.