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Patient Assistance Forms for Individuals Without Insurance These forms help individuals without insurance apply for patient assistance programs on their own.
If you do not have insurance, you can download and complete the forms below to request medication support directly.
CAPLYTA Patient Assistance Call 1‑833‑742‑0791 Monday–Friday, 8 AM–8 PM ET Support for affordability programs, insurance questions, and treatment resources.
Vraylar Patient Assistance Form
Download and complete this form to apply for Vraylar medication assistance.
Phone: 1‑800‑222‑6885 Fax: 1‑866‑250‑2803
Patients can use these contact numbers for help with AbbVie medications, including Vraylar, Humira, Skyrizi, and others.
Ingrezza Patient Assistance Program.Patietns can apply for assistance with Ingrezza through Neurocrine Access Support.
Download and complete the form below. Ingrezza Patient Assistance Program Phone: 1‑844‑852‑6333 Fax: 1‑877‑271‑8301
Rexulti (Otsuka Patient Assistance Foundation)Phone: 1‑855‑727‑6274 📠 Fax: 1‑844‑727‑6274
Abilify Maintena Patient Assistance Program
Phone: 1‑855‑727‑6274 Fax: 1‑844‑727‑6274 Patients can apply for assistance with Abilify Maintena through the Otsuka Patient Assistance Foundation.
Abilify Asimtufii Patient Assistance Program
Phone: 1‑855‑727‑6274 Fax: 1‑844‑727‑6274 Patients can apply for assistance with Abilify Asimtufii through the Otsuka Patient Assistance Foundation.
Trintellix Patient Assistance Program
Phone: 1‑866‑701‑7171 Fax: 1‑888‑701‑6015 Patients can apply for assistance with Trintellix through the Takeda/Lundbeck Patient Assistance Program.
Abbvie / my Abbvie Assit Phone:1-800-222-6885 Fax: 1-866-250-2803