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Program Details

INCYTE CORPORATION
IncyteCARES Patient Assistance Program - Jakafi

Jakafi Tablet (ruxolitinib)
 
CONTACT INFO
Address: PO Box 221798
Charlotte, NC 28222-1798
Phone: 1-855-452-5234 Provider Phone:
Fax: 1-855-525-7207 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must not have prescription coverage for needed medication or have exhausted or been denied coverage for Jakafi and meet household income criteria.
  • Patients enrolled in Medicare Part D may be eligible, contact program for details.
  • Medication must be used for an FDA-approved diagnosis.
  • Program also offers co-pay assistance for eligible patients.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Proof of insurance, if applicable
    Physician License #
    Required:
    Both DEA and State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Up to 90-day supply
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Contact the program for refills
    Other Information:

    Last Updated: 11/22/2024

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)



     

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