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 | $60,240 |
| 2 people | $81,760 |
| 3 people | $103,280 |
| 4 people | $124,800 |
| 5 people | $146,320 |
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 2024 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 Pharmaceutical Assistance Program (SPAP)
To Apply:
Complete and submit the Patient Assistance Program Enrollment Form for OPZELURA. You and your patient will need to complete all pages 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 Patient Assistance Program 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 1 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 enrollment form is received, a Case Manager will review to confirm your patient’s eligibility for the 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.
- Uninsured: Patients are enrolled up to 12 months, and after that, they must apply to be re-enrolled
- Medicare Part D coverage: Patients are enrolled for the calendar year and must re-enroll each year
Your patient must call IncyteCARES for OPZELURA at 1-800-583-6964 to refill their prescription for OPZELURA.
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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