Patient Assistance Program - Otezla 2025

1. Click ‘Get Form’ to open the Patient Assistance Program - Otezla application in the editor.
2. In Section A, enter your personal information including your name, date of birth, address, and contact details. Ensure all fields are filled accurately.
3. If you have insurance, check the appropriate boxes and provide details about your insurance coverage. If you do not have insurance, indicate that as well.
4. In Section B, your healthcare provider must complete the diagnosis and prescriber information. This includes entering the primary diagnosis and providing their contact details.
5. Attach required financial documents such as tax returns or proof of income to support your application. Make sure to include a letter if your income has changed significantly.
6. Review all sections for completeness before submitting. Once finalized, fax the completed form and documents to 1-844-269-3053 or mail them if necessary.

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