Welcome to the Verkazia patient access support program

Our patient support team is here to help

Whether you’re a patient or parent, provider or pharmacist, we’re here to help. We are committed to providing access to Verkazia for those most in need.
Patients who are experiencing financial hardship and have limited or no prescription coverage may be eligible to receive financial assistance.

Below are a few ways you can enroll yourself or others.

Online

Select one of the forms below to get started. Once it’s filled out, just hit Submit and a representative will reach out to you.

Phone

Call 1-833-577-7277 (8 AM to 8 PM ET M-F) to enroll over the phone. You can also call this number for general inquiries, support, and more.

Fax

If you’re a provider and would like to enroll your patients in the Verkazia patient access support program, complete this enrollment form and fax it to 1-833-577-2866.

Enter your information below if you’re a patient or caregiver interested in learning how to get started with Verkazia. patient or caregiver interested in learning about benefit determination for Verkazia. patient or caregiver interested in learning about eligibility for Verkazia copay assistance. healthcare professional interested in Verkazia for your patients, practice, or pharmacy.
I am interested in Verkazia information for a
PATIENT HIPAA AUTHORIZATION FOR SANTEN SERVICES (Read/scroll through entire content below to continue)

I hereby authorize my healthcare providers, my health insurance company, and my pharmacy to disclose my protected health information (PHI) including, but not limited to, my name, address, telephone number, medical records, health insurance coverage, and financial information to Santen Incorporated and companies working with Santen Incorporated (collectively “Santen Incorporated”) and its agents for the following purposes:

  • Contact me, or the person legally authorized to sign on my behalf, by phone or mail for Santen PASS purposes
  • I authorize calls/texts may mention the name of Santen products or services, details about my insurance coverage and my doctor’s name. I understand that I am not required to consent to being contacted by phone or text message as a condition of any purchase of Santen products or enrollment. Message and data rates may apply. I understand that I may opt out of receiving these communications at any time by calling Santen PASS
  • Contact my insurance company on my behalf to verify my coverage for Verkazia 1 mg/mL eye drops
  • Determine my eligibility, and enroll in the Commercial Copay/Coinsurance Assistance Program
  • Determine my eligibility, and enroll in the Patient Assistance Program (PAP), including verification of my financial information
  • Coordinate my treatment with my healthcare provider and specialty pharmacy
  • Send me educational materials or other program information that may be of interest to me
  • Send reminders about refilling medication for adherence support

I understand that Santen Incorporated may offer an ongoing customized patient support program. The support program could include a care coordinator contacting me by telephone, email, or text to provide ongoing personalized support over a period of time.

Once my health information has been disclosed to Santen Incorporated, I understand that federal privacy laws may no longer protect the information. However, I understand that Santen Incorporated and other companies authorized to receive my health information pursuant to this authorization agree to protect my health information by using and disclosing it only for purposes authorized in this authorization or as required by law or regulations. I understand that this authorization does not affect treatment from my healthcare provider or coverage for Verkazia 1 mg/mL eye drops through my insurance.

I understand that this authorization is voluntary. However, if I refuse to sign, or cancel my authorization, Santen Incorporated may not be able to determine my eligibility for the Commercial Copay/Coinsurance Assistance Program or the Patient Assistance Program (PAP). I may cancel this authorization at any time by mailing a letter to PO Box 5490, Louisville, KY 40255. This authorization expires five [5] years from the day that I sign it as indicated by the date next to my signature, unless (i) otherwise canceled as set forth above, (ii) the patient reaches the age of majority, or unless (iii) a shorter period is mandated by the law of my state of residence. I understand that canceling this authorization is not effective to the extent that any person or entity has already acted in reliance on my authorization.

I understand that my pharmacy, health insurers, and third-party vendors may receive remuneration (payment) from Santen Incorporated in exchange for disclosing my personal information to Santen Incorporated and/or for providing me with support services for the purposes described above.

I understand and have read this authorization. I understand that I am entitled to receive a signed copy of this form and can do so by calling Santen PASS at 1-833-577-PASS (7277) or by mailing a request to the address above.

Thank you for your submission

A representative will reach out to you soon.