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NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) capsules Enrollment Application

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New Provider Form ABILIFY MAINTENA® (aripiprazole) Medical Necessity Form

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Enrollment Application for ABILIFY MAINTENA® (aripiprazole) extended-release injectable suspension

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Enrollment Application for ABILIFY ASIMTUFII® (aripiprazole) extended-release injectable suspension

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ABILIFY MAINTENA® (aripiprazole) Refill Request Form

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Enrollment Application for REXULTI® (brexpiprazole) tablets

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Enrollment Application for NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) capsules

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New Provider Form REXULTI® (brexpiprazole) Medical Necessity Form

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Medical Necessity Letter SAMSCA® (tolvaptan)

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New Provider Form SAMSCA® (tolvaptan) Medical Necessity Form

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Re-initiation of Therapy Form SAMSCA® (tolvaptan)

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Enrollment Application for SAMSCA® (tolvaptan) tablets

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Enrollment Application for JYNARQUE® (tolvaptan) tablets

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New Provider Form JYNARQUE® (tolvaptan) Medical Necessity Form

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Income Insurance Residency Attestation Letter

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Additional Antidepressant Request Form

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Vitamins Request Form

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Supported Medications

OPAF provides eligible patients no-cost support for the following prescribed medications:

Abilify Maintena logo
Abilify Asimtufii logo
nuedexta logo
jynarque logo
rexulti logo
samsca logo

See U.S. FULL PRESCRIBING INFORMATION for NUEDEXTA.
See U.S. FULL PRESCRIBING INFORMATION, including BOXED WARNING for ABILIFY MAINTENA, ABILIFY ASIMTUFII, JYNARQUE, REXULTI, and SAMSCA.
See MEDICATION GUIDES for ABILIFY MAINTENA, ABILIFY ASIMTUFII, JYNARQUE, REXULTI, and SAMSCA.

To report SUSPECTED ADVERSE REACTIONS, contact Otsuka America Pharmaceutical, Inc. at
1-800-438-9927 or FDA at 1-800-FDA-1088 (www.fda.gov/medwatch).

Otsuka America Pharmaceutical, Inc. does not control or influence how Otsuka Patient Assistance Foundation, Inc. distributes funds.

Secure Messaging

Secure messaging ensures patient privacy because it is a HIPAA-compliant, password-protected electronic messaging platform. You can communicate directly with an OPAF Patient Access Advocate without having to pick up the phone. Through the platform you can securely send electronic messages with any questions, communications, and documents at your convenience.

Because it is HIPAA-compliant, there is a one-time account activation process. The activation process takes less than 3 minutes. Once your account is active, you can send messages to OPAF immediately.

To setup your OPAF secure message account follow the steps below:

  • Click on the (button or envelope) below to start the process
  • The system will prompt you to enter your email address as a "New to SecureContact"
  • A verification email will be sent to the email address that you entered
  • In your email inbox, you will find a message from "[email protected]"
  • Open this message and click on the link to activate your account
  • Complete the account activation by creating a password
  • Your account is active, and you can securely send a message to OPAF

If you have any questions, please contact OPAF at 1-855-727-6274 8:00 AM - 8:00 PM ET.

MESSAGE US

message

Welcome to the Otsuka Patient Assistance Foundation, Inc.

OTSUKA logo

IMPORTANT MESSAGE  
FROM  
THE OTSUKA PATIENT ASSISTANCE FOUNDATION, INC.

Per federal regulations, patients with government issued insurance such as Medicaid and Medicare that are, also, enrolled with the Otsuka Patient Assistance Foundation, Inc. (OPAF) for free medications, will have their OPAF enrollment end on December 31st, 2024. On November 15th, 2024, an OPAF 2025 application packet will be mailed to currently enrolled Medicare and Medicaid patients. Once an OPAF application has been submitted, our dedicated Patient Access Advocates will review and provide an enrollment determination on or after January 2nd, 2025. Please ensure to submit a completed application with all supporting documentation.

If you have any questions, you may contact us at 1-855-727-6274 Monday-Friday 8 AM-8 PM EST or You may send a SECURE MESSAGE by using the “Message Us” red icon below. OPAF’s secure message platform is password protected and HIPAA compliant. Your message will be received, and our Patient Access Advocates will respond shortly.

During this time, OPAF may experience higher call volumes, which may result in longer wait times. Please have patience as we help everyone needing OPAF assistance.

November 2024    PAUS24EUC0155