#COPAY ASSISTANCE PROGRAMS VERIFICATION#
#COPAY ASSISTANCE PROGRAMS PROFESSIONAL#

Submit a copy of prescription drug expenses from your pharmacy that is signed and dated by the pharmacist.

Submit your most recent Explanation of Benefits letter from your Medicare prescription drug plan.

For Proof of Prescription Costs, you can either:

#COPAY ASSISTANCE PROGRAMS VERIFICATION#

Submit your most recent federal income tax return (Form 1040), your most recent W-2 earnings statement from your employer, your most recent Social Security Benefit Verification Letter, or one month of your recent pay stubs.Sign section 8 of this form, and we can verify your income electronically.For Income Documentation, you can either: Note: In addition to your application, you must provide proof of both your household income and your prescription medicine costs for the year to date. Or call IncyteCARES for OPZELURA at 1-80, Monday through Friday, 8 AM–8 PM ET. You’ll both need to complete and sign certain parts of it.

#COPAY ASSISTANCE PROGRAMS PROFESSIONAL#

This documentation must then be submitted to the IncyteCARES for OPZELURA teamĪsk your Healthcare Professional to start the program application by completing an IncyteCARES for OPZELURA Prescription and Enrollment form. Your pharmacy or your health plan can provide you with documentation regarding your out-of-pocket prescription costs. You must pass a means test that proves your total out-of-pocket prescription costs exceed 10% of your household income.Any State Patient Assistance Program (SPAP).Medicare Part D Low-Income Subsidy (LIS) program.

You are not a beneficiary of any of these government insurance or healthcare programs including, but not limited to:.You are enrolled in a Medicare Part D prescription insurance plan and have expressed and documented an inability to afford your out-of-pocket cost.You are uninsured or have medical insurance but no coverage for prescription medicines.Income levels are subject to change on an annual basis the numbers in this table are based on the 2022 Federal Poverty Level Guidelines.Īdditional eligibility criteria depend on your insurance type: If you live in Alaska or Hawaii or have a household with more than 5 members, please call 1-80 to see if you may qualify.

Copay assistance programs