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IncyteCARES Patient Assistance Program
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PO Box 221798
Charlotte, NC 28222
Phone
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855-452-5234
Fax:
855-525-7207
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Eligibility
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The IcyteCARES Patient Assistance Program provides brand name medications at no or low cost and is intended for patients that have no prescription coverage for needed medication. Medicare Part D patients are not eligible. Patients must be a resident of the US or Puerto Rico. Gross family household income must be at or less than $125,000 or 600% Federal Poverty Level, whichever is greater. Patients must also meet FDA-approved diagnosis criteria. |
| Who Can Apply
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Doctors or doctor's office must call or download the application. |
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Required
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Doctors and patients must complete and sign the application. Proof of income and insurance information must be faxed along with the application. Doctor and patient will be notified within 48 hours. |
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Supply
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Up to a 90 day supply. |
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Ship To
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Medication will be shipped to the doctor's office or the patient's home. Patient or doctor must contact the company for refills. |
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Note
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Patient or doctor's office can call the program to apply.
Patient must sign the enrollment form to give the program permission to access their financial information in order to determine eligibility.
Conditional approval for 90 days.
Education and support services are available.
This program also provides copay assistance. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Jakafi tablet |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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