Some patients with commercial prescription drug insurance may initially be denied coverage for OPZELURA after prior authorization (PA) submission. If a prior authorization is denied, your patient may be eligible for the Commercial Access Program. Through this Program, patients may be eligible to receive a limited quantity of OPZELURA at no cost.*
To be eligible for the Commercial Access Program, your patient must:
  • Have commercial prescription drug insurance
  • Have been denied coverage for OPZELURA by their payer through a PA or non-formulary exception form
  • Have been prescribed OPZELURA for an FDA-approved indication
  • Be considered clinically appropriate for OPZELURA based on the product prescribing information
To Apply:
After you have received a prior authorization denial from the patient’s health plan, complete and submit the Prescription and Enrollment Form for OPZELURA. Be sure to complete pages 1 and 2 of the form for the Commercial Access Program.

Download Form

 

Prescription Fulfillment:

Once a completed Prescription and Enrollment Form for OPZELURA is received, a Case Manager will review to confirm the patient’s eligibility for the Commercial Access Program. If the patient is eligible, the prescription will be triaged to the designated Program pharmacy.

The patient will be shipped one tube of OPZELURA at no cost. If a second tube of OPZELURA is requested, an appeal must first be submitted to the patient’s health plan. See below for information on appeals support.

Appeal Support:

To appeal the PA denial from the patient’s health plan, a Case Manager can provide you with appeals support as outlined below:

  • We will contact the health plan to obtain information on how to submit an appeal and will provide that information to you
  • You submit the appeal directly to the patient’s health plan
  • We follow up with the plan to obtain the appeal outcome

Appeal Denied: If the appeal is denied, the patient may be eligible to receive an additional tube of OPZELURA at no cost.

Appeal Approved: If the appeal is approved, the prescription will be triaged to the patient’s preferred pharmacy where the patient can use a copay savings card, if eligible.

We will follow up with the patient’s health plan at 45 and 90 days post-enrollment to determine if access to OPZELURA may be available and will notify your team accordingly.

 

Prescription Fulfillment:

After a completed enrollment form is submitted, eligible patients may start receiving OPZELURA from the designated Program pharmacy.

Within 90 days of enrollment, an appeal must be submitted to the patient’s health plan.

Appeal Support Required:

To appeal the PA denial from the patient’s health plan, a Case Manager can provide you with appeals support as outlined below:

  • We will contact the health plan to obtain information on how to submit an appeal and will provide that information to you
  • You submit the appeal directly to the patient’s health plan
  • We follow up with the plan to obtain the appeal outcome

After appeal submission, prescription fulfillment is determined by the appeal outcome.

Appeal Denied: If the appeal is denied, the patient may continue to receive OPZELURA through the Commercial Access Program at no cost for up to 12 months. A Case Manager will regularly conduct a benefits investigation to monitor your patient’s coverage for OPZELURA.

Appeal Approved: If the appeal is approved, the prescription will be triaged to the patient’s preferred pharmacy where the patient can use a copay savings card, if eligible.

*Terms and Conditions apply. Terms of this Program may change at any time.