Anzupgo® Access and Patient Support Resources

US EXPERT RECOMMENDATIONS for the management of adults with CHE: Delgocitinib cream ^1,2

1

Prescribe
ANZUPGO to a
limited distribution
network pharmacy

Apotheco Pharmacy Group

Phone: 1-973-870-0544

Fax: 1-973-870-0544

NCPDP ID: 3153258

Carepoint Pharmacy

Phone: 1-855-237-9112

Fax: 1-855-237-9113

NCPDP ID: 1487330

DFW Wellness Pharmacy

Phone: 1-817-459-8400

Fax: 1-817-459-8402

NCPDP ID: 5903491

Review key information to prevent delays in getting
your patients started on ANZUPGO.

No additional paperwork or enrollment forms needed.

Download pharmacy list

No additional paperwork or enrollment forms needed.

2

While awaiting
a
coverage
decision

ANZUPGO®
BRIDGE PROGRAM^†

ANZUPGO® BRIDGE PROGRAM^†

Patients can be enrolled by the pharmacy and
may receive a limited supply of ANZUPGO at no cost.

3

Following
coverage
approval

ANZUPGO®
COPAY PROGRAM*

ANZUPGO® COPAY PROGRAM*

Patients are automatically enrolled by the
pharmacy and may pay as little as $0 per 30 g tube.

Activate copay card

For pharmacies only

*Eligible, commercially insured patients may pay as little as $0 per 30 g tube through the ANZUPGO Copay Program. See full Terms, Conditions, and Eligibility Rules.^†Eligible, commercially insured patients may be able to receive a limited supply of ANZUPGO at no cost. See full Terms, Conditions, and Eligibility Rules.

ANZUPGO Patient Assistance Program (PAP):

Helps patients with demonstrated financial need and limited or no prescription coverage.
Connect with the ANZUPGO® Let's GO^TM Support Program to learn more.

ANZUPGO Patient Assistance Program^‡

For your eligible patients with demonstrated financial need and limited or no prescription coverage, ANZUPGO can be dispensed through the ANZUPGO^® Let's GO^TM Support Program.

More on PAP

^‡See full Terms, Conditions, and Eligibility Rules.

For ANZUPGO access assistance, call
1-855-ANZUPGO (269-8746), Monday-Friday, 8 ᴀᴍ – 8 ᴘᴍ ET

Help your patients access ANZUPGO

Ready to prescribe ANZUPGO?

Include the key information below to prevent delays in getting your patients started on ANZUPGO:

Remember to include an ICD-10-CM code. There is no approved ICD-10-CM code for CHE. Examples of ICD-10-CM codes that may be used include^§:

Atopic dermatitis: L20.89, L20.9
Allergic contact dermatitis: L23.0-L23.9
Irritant contact dermatitis: L24.0-L24.B3
Protein contact dermatitis: L25.0-L25.9
Acute, recurrent vesicular (dyshidrosis): L30.1
Hand dermatitis: L30.8

ANZUPGO Rx Instructions resource

Download Rx Instructions

ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification; TCS=topical corticosteroids.

^§The coding information in this resource is provided for informational purposes only and is subject to change. The ICD-10-CM codes listed may not apply to all patients or to all health plans; it is the responsibility of the healthcare provider to select the appropriate ICD-10-CM code(s) and submit claims that accurately reflect the services and products furnished to a specific patient.

Need to request a medical exception or submit a prior authorization for ANZUPGO?

Support is available to help you and your office staff identify and understand different payer process requirements across various insurance plan types, so you can accurately respond to prior authorizations (PAs) and denials.

Be sure to include:

Patient’s age: The patient must be 18 years or older.¹
Diagnosis: ANZUPGO is indicated for adults with moderate-to-severe Chronic Hand Eczema (CHE).¹
Example ICD-10-CM code(s): See a list of example codes above
Step-through therapy: Typically, a 4-week trial of a topical corticosteroid (TCS) and/or a topical calcineurin inhibitor (TCI) within the past year. Document tried/failed or unacceptable therapies and associated side effects. Include duration of use and discontinuation dates.³
Not used in combination: Confirm ANZUPGO will not be used with³:
- Other JAK inhibitors (including topicals)
- Potent immunosuppressants
Chronicity and severity of condition:
- Chronicity: CHE >3 months or relapsed ≥2x within a year³
- Severity: If available, include results of an outcome measure used to document the severity of your patient’s CHE.¹
Chart notes: Ensure above information is documented for each patient prescribed ANZUPGO. Some plans will require a copy of the chart notes.

Download Sample Letter of Medical Exception and Medical Necessity

Medical Exception and Medical Necessity Checklist

Refer to this checklist when preparing a letter of medical exception and/or medical necessity to submit to your patient’s health insurance plan.

Download Checklist

Prior Authorization Checklist

Refer to this checklist when preparing a prior authorization submission to your patient’s health insurance plan.

Download PA Checklist

PA denied? Here’s what to do next:

Determine the reason for the denial
Find out the time frame for submitting an appeal
Contact the health plan directly to obtain information on its appeals process

Download Sample Letter of Appeal

Appeal Checklist

Refer to this checklist if a request for coverage of ANZUPGO is denied and an appeal is appropriate.

Download Appeal Checklist

Accessing
Anzupgo is as
easy as 1-2-3
for eligible, commercially insured patients

Now Nationally
Preferred

Before & after images

Rapid, powerful efficacy

INDICATION

IMPORTANT SAFETY INFORMATION AND INDICATION

IMPORTANT SAFETY INFORMATION

REFERENCES:

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Accessing Anzupgo is as easy as 1-2-3 for eligible, commercially insured patients

Now Nationally Preferred

AS LITTLE AS $0