For adults with moderate to severe ulcerative colitis (UC).

#1 prescribed biologic for Crohn's and ulcerative colitis combined.

†Quarterly analysis of claims data from January 2023–December 2025.

Sign up for EntyvioConnect

EntyvioConnect is here to support you every step of the way. Whether you're just starting treatment with ENTYVIO or continuing your journey, enrolling in EntyvioConnect gives you access to a dedicated team of caring experts and helpful resources—all designed to make your experience as stress-free as possible. Take a few minutes and fill out the form below to get started.

1

Your Current Treatment

All fields marked with * are required.

Which condition have you been diagnosed with?*
Are you currently taking or about to start taking ENTYVIO?*
Which ENTYVIO maintenance option were you prescribed?*

Thank you for your interest. The EntyvioConnect program is for patients on ENTYVIO only. However, you can still receive helpful information, advice, and tips by clicking below.

Sign up for more information

2

Service Selection

In addition to getting access to emails with tips and advice, based on the information you provided, you can also sign up for the following EntyvioConnect services. Check which services you would like to sign up for: (optional)

Our co-pay and other financial resources, like the downloadable savings card, may help you save on out-of-pocket costs. Our experts can help navigate your insurance coverage and any eligibility requirements.

Our Nurse Educators provide one-on-one guidance, resources, and support to help you get started and stay on track with your treatment as prescribed by your doctor. They cannot, however, provide medical advice.

Get helpful reminders about your next treatment sent straight to your phone via text message.

Thank you for your interest in Co-Pay & Insurance Help.

You must choose “yes” to all the following questions to enroll in the program. If you have questions or need help, call 1-844-ENTYVIO (1-844-368-9846).

Do you certify that you currently have commercial insurance that covers a portion of your prescription costs for ENTYVIO?*
Do you certify that you are not enrolled in any federal or state healthcare program (Medicare, Medicaid, TRICARE, etc.), including a state pharmaceutical assistance program?*
Do you certify that you will not seek reimbursement from any other plan or program (Flexible Spending Account [FSA], Health Savings Account [HSA], Health Reimbursement Account [HRA], etc.) for any out-of-pocket costs covered by the Co-Pay Assistance Program?*
Do you understand that you or your doctor will need to submit your Explanation of Benefits (EOB) following each infusion, and that the Program cannot provide co-pay assistance without an EOB?*

The EntyvioConnect Co-Pay Program (“Co-Pay Program”) provides financial support for commercially insured patients who qualify for the Co-Pay Program. Participation in the Co-pay Program and provision of financial support is subject to all Co-Pay Program terms and conditions, including but not limited to eligibility requirements, the maximum benefit per claim and the Maximum Annual Benefit. By enrolling in the Co-Pay Program, you agree that the program is intended solely for the benefit of you—not health plans and/or their partners. Further, you agree to comply with all applicable requirements of your health plan. The Co-Pay Program cannot be used if the patient is a beneficiary of, or any part of the prescription is covered by: 1) any federal, state, or government-funded healthcare program (Medicare, Medicare Advantage, Medicaid, TRICARE, etc.), including a state pharmaceutical assistance program (the Federal Employees Health Benefit (FEHB) Program is not a government-funded healthcare program for the purpose of this offer), 2) the Medicare Prescription Drug Program (Part D), or if the patient is currently in the coverage gap, or 3) insurance that is paying the entire cost of the prescription. Takeda reserves the right to change or end the Co-Pay Program at any time without notice, and other terms and conditions may apply.

CLICK HERE FOR A PRINTABLE COPY OF THE CO-PAY PROGRAM TERMS AND CONDITIONS

3

Your Contact Information

*Required field

To support you every step of the way, we will need to keep in contact with you. Please provide the following for our future communications:

Sex on file with your insurance company*

According to our records, you are already enrolled in EntyvioConnect. Please contact EntyvioConnect at 1-855-ENTYVIO for any questions about your enrollement or services.

4

Your Doctor’s Information

*Required field

Please provide your doctor's information so we can help you manage your insurance and coverage, and identify available financial support options.

Patient HIPAA Authorization

HIPAA AUTHORIZATION INFORMATION

By signing the Patient Authorization section of this EntyvioConnect Form, I authorize my physician, health insurance, and pharmacy providers (including any specialty pharmacy that receives my prescription) to disclose my protected health information, including, but not limited to, information relating to my medical condition, treatment, care management, and health insurance, as well as all information provided on this form (“Protected Health Information”), to Takeda Pharmaceuticals U.S.A., Inc. and its present or future affiliates, including the affiliates and service providers that work on Takeda’s behalf in connection with the EntyvioConnect Patient Support Program (the “Companies”). The Companies will use my Protected Health Information for the purpose of facilitating the provision of the EntyvioConnect Patient Support Program products, supplies, or services as selected by me or my physician and may include (but not be limited to) verification of insurance benefits and drug coverage, prior authorization education, financial assistance with co-pays, patient assistance programs, and other related programs. Specifically, I authorize the Companies to 1) receive, use, and disclose my Protected Health Information in order to enroll me in EntyvioConnect and contact me, and/or the person legally authorized to sign on my behalf, about EntyvioConnect; 2) provide me, and/or the person legally authorized to sign on my behalf, with educational materials, information, and services related to EntyvioConnect; 3) verify, investigate, and provide information about my coverage for ENTYVIO, including but not limited to communicating with my insurer, specialty pharmacies, and others involved in processing my pharmacy claims to verify my coverage; 4) coordinate prescription fulfillment; and 5) use my information to conduct internal analyses.

I understand that employees of the Companies only use my Protected Health Information for the purposes described herein, to administer the EntyvioConnect Patient Support Program or as otherwise required or allowed under the law, unless information that specifically identifies me is removed. Further, I understand that my physician, health insurance, and pharmacy providers may receive financial remuneration from the Companies for providing Protected Health Information, which may be used for marketing purposes. I understand that Protected Health Information disclosed under this Authorization may no longer be protected by federal privacy law. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization and that instructions for doing so are contained in Takeda’s Website Privacy Notice available at www.takeda.com/privacy-notice/. I can also revoke my Authorization by emailing PrivacyOffice@takeda.com, by calling 1-855-268-1825, or by sending written notice of revocation to EntyvioConnect, PO Box 2355, Morristown, NJ 07962. I may revoke this Authorization at any time by sending written notice of revocation to EntyvioConnect, PO Box 2355, Morristown, NJ 07962. I understand that such cancellation will not apply to any information already used or disclosed through this Authorization. This Authorization will expire within five (5) years from the date it is signed and provided below, unless a shorter period is provided for by state law. I understand that I may refuse to sign this Authorization and that refusing to sign this Authorization will not change the way my physician, health insurance, and pharmacy providers treat me. I also understand that if I do not sign this Authorization, I will not be able to receive EntyvioConnect Patient Support Program products, supplies, or services.

Digital Signature

Signature must match First Name and Last Name you provided previously:

EntyvioConnect Patient Support Program Enrollment

HIPAA AUTHORIZATION INFORMATION

By signing below, I acknowledge I have read the EntyvioConnect Patient Support Services Terms & Conditions and choose to enroll. I authorize the use and disclosure of my personal and health information to provide services that may include insurance benefit and drug coverage verification, prior authorization support, financial assistance programs, disease state or product education, and communications with me or my prescribing physician by mail, email, or phone about my care, treatment, product information, or health insurance. I understand Takeda and its business partners may use and share my personal and health information with my healthcare providers, pharmacies, and health insurance plans to support my care, to meet its legal obligations, and de-identified data for internal use.

I have read, understand, and agree to the use of my personal information for the purposes described above.

Digital Signature

Signature must match First Name and Last Name you provided previously:

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