For Eligible Patients Who Are Uninsured or Underinsured with Medicare Part D Coverage
Patients who are uninsured or underinsured with Medicare Part D coverage may be eligible to receive OPZELURA at no cost.* Your patient must have an expressed and documented inability to afford their out-of-pocket cost.
Patients are considered uninsured if they have no prescription insurance or have medical insurance but no coverage for their prescription medications.
To be eligible for this Program, your patient must:
- Be uninsured or underinsured with Medicare Part D coverage and cannot afford their copay
- Have been prescribed OPZELURA for an FDA-approved indication
- Have an adjusted annual household income that is less than or equal to 400% of the Federal Poverty Level (FPL)
| If this many people live in your | Your patient may qualify if their full-year income |
|---|---|
| 1 person | $58,320 |
| 2 people | $78,880 |
| 3 people | $99,440 |
| 4 people | $120,000 |
| 5 people | $140,560 |
If your patient lives in Alaska or Hawaii or has a household with more than 5 members, please call IncyteCARES for OPZELURA at 1-800-583-6964 to see if they may qualify.
Income levels are subject to change on an annual basis; the numbers in this table are based on the 2023 Federal Poverty Level Guidelines.
Additional eligibility criteria for patients who are underinsured with Medicare Part D coverage:
- Patient must not be a beneficiary of any other government insurance or healthcare programs including, but not limited to: Medicaid, Medicare Part D Low-Income Subsidy (LIS) program, Veterans Affairs (VA), the Department of Defense (DoD), TRICARE, or any State Patient Assistance Program (SPAP)
To Apply:
Complete and submit the Prescription and Enrollment Form for OPZELURA. Be sure to check the box for the Patient Assistance Program at the top of page one on the form. You and your patient will need to complete pages 1, 2, and 3 of the form.
- Proof of income must be provided. Income can be verified electronically if the patient completes and signs the Electronic Income Verification section of the PAP application on the form. Alternatively, your patient can submit their most recent federal income tax return (Form 1040), W-2 earnings statement from their employer, Social Security Benefit Verification Letter, or one month of their recent pay stubs. The required documentation can be faxed with the Program application, or mailed to IncyteCARES for OPZELURA PAP, 6000 Park Lane, Pittsburgh, PA 15275.
If your patient has not been approved for the Program, they may appeal the decision.
Prescription Fulfillment:
Once a completed Prescription and Enrollment Form for OPZELURA is received, a Case Manager will review to confirm your patient’s eligibility for the Patient Assistance Program. Our team will inform both you and your patient of the outcome of the patient’s application.
If the patient is eligible and approved, the prescription will be triaged to the designated Program pharmacy and shipped to your patient. Your patient will need to reapply each calendar year to continue to receive their medication at no cost.
If your patient is eligible, they will be shipped one 60-gram tube of OPZELURA.
If your patient needs a refill of their prescription for OPZELURA, they will receive a call from the designated Program pharmacy.
If your patient’s insurance coverage or financial status changes while participating in the Program, you or your patient should contact IncyteCARES for OPZELURA to update their patient profile.
If your patient is eligible, they will be shipped two 60-gram tubes of OPZELURA.
If your patient needs a refill of their prescription for OPZELURA, they will receive a call from the designated Program pharmacy.
If your patient’s insurance coverage or financial status changes while participating in the Program, you or your patient should contact IncyteCARES for OPZELURA to update their patient profile.
*Terms and Conditions apply. Terms of this Program may change at any time.
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