Access an IncyteCARES for Jakafi Enrollment Form.
A completed IncyteCARES for Jakafi Program Enrollment Form can also serve as your patient's first prescription. Completion takes about 15 minutes.
Your Incyte representative can also provide
There’s no need to set up an account or password.
eligible to enroll in IncyteCARES for Jakafi or to receive all services we provide.
Contact IncyteCARES for Jakafi at 1-855-452-5234 for more information.
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:
- Patient shipping address for medication delivery
- 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
- Patient’s prescription details
Step 3: Review and sign the Physician Declaration (You can e-sign the online enrollment form)
Step 4: Submit the IncyteCARES Program Enrollment Form with or without the signed Patient Authorization
You can have your patient sign the Patient Authorization section of the enrollment form before you submit it. Or you can leave it blank and IncyteCARES for Jakafi will call your patient to get verbal authorization for the program.
Once an eligible patient is enrolled, an IncyteCARES for Jakafi representative will call to:
- Review coverage and costs for the prescribed medication
- Coordinate the patient’s prescription and monthly delivery with an appropriate specialty pharmacy
- Offer financial assistance options for which the patient may be eligible
- Explain other resources and support available to the patient during treatment
Did You Know?
Sometimes, patients contact IncyteCARES for Jakafi directly to start an enrollment form. In that case, a representative will take the patient’s information and may call the prescriber’s office to gather the additional information needed to qualify and enroll the patient.