Access an IncyteCARES Enrollment Form for Your Patients
Prescribed Niktimvo™ (axatilimab-csfr)
A completed IncyteCARES Program Enrollment Form can also serve as your patient's first prescription for Niktimvo.
Completion takes about 15 minutes.
Submit Via Fax
This PDF form for Niktimvo can be downloaded and filled out on computer to print and sign or can be printed and filled out by hand before faxing.
Patients who have been prescribed Niktimvo can enroll in IncyteCARES but may not be eligible to receive some of the services or support we offer. Contact IncyteCARES at 1-855-452-5234 for more information.
For Eligible Patients With Commercial Prescription Drug Coverage
Enroll Your Patient in the Savings Program Only
Follow These Simple Steps
Save time by gathering required patient information before you start!
Step 1: Complete the Patient Information (or have your patient complete it) including:
- Contact phone number(s)
- Prescription insurance information
- Financial information (if being considered for
Patient Assistance Program)
Step 2: Complete the Physician Information including:
- Practice and provider information
- Patient’s clinical information
- Details about patient's prescription for Niktimvo
Step 3: Fax or submit an IncyteCARES Program Enrollment Form
- Form can be submitted with or without the signed patient HIPAA Authorization and Patient Opt-in for Ongoing Education and Support
- If the patient is available, have them sign the HIPAA Authorization and Patient Opt-in for Ongoing Education and Support sections
- If the patient isn’t available to sign those sections, they can be left blank and IncyteCARES will call the patient to get verbal authorization
Patient authorization is not needed for benefits verification.
When You Enroll a Patient, an IncyteCARES Nurse Navigator Will:
- Call your patient to welcome them and explain their insurance coverage
- Assess your patient’s eligibility for savings or financial assistance programs* and help them enroll
- Explain the importance of tracking and reporting all symptoms to their transplant physician
- Explain the additional support and resources available to them during treatment
The patient will also receive follow-up calls from the same IncyteCARES Nurse Navigator in 2-week intervals. The focus of these calls will be to check in with the patient on how their infusions are going, answer any questions the patient may have, and remind them to track and report all symptoms or changes in their health to their transplant team.
*Terms and conditions apply. Terms of this program may change at any time.
Did You Know?
Sometimes, patients contact IncyteCARES directly to start an enrollment. In that case, a representative will take the patient’s information and will contact the prescriber’s office to gather the additional information needed to qualify and enroll the patient.
Contact IncyteCARES
Our team is available Monday through Friday, 8 AM–8 PM ET
Call us at 1-855-452-5234