HOW TO APPLY
Complete the 3 steps below to apply for
Download & Complete
Both patients and their doctors must complete their own sections of the enrollment form.Download Application
For health care professionals: Please refer to the
ICD-10-CM codeswhen completing the enrollment form.
Mail or Fax
Send Application in a Self-Addressed Envelope to:
Otsuka Patient Assistance Foundation, Inc.
PO Box 220248
Charlotte, NC 28222-0248OR
Fax Completed Application to
What Happens Next?
The application will be reviewed.
In response to a completed application, patients will receive a letter letting them know if they are qualified to receive no-cost medication from the Otsuka Patient Assistance Foundation, Inc.
Patients must reapply each year.
Patients receiving government issued insurance (Medicare, Medicare Part D, Medicaid) will need to reapply at the end of every calendar year. Other qualified patients not on a government issued insurance program must reapply every 12 months.
Need further assistance?
Patients treated with
Have a question?
Find answers to common questions on our Frequently Asked Questions (FAQs) page.
Otsuka Patient Assistance Foundation, Inc. (OPAF) provides support for the following medications: