LOKELMA IS COVERED* FOR 90% OF COMMERCIAL AND MEDICARE PART D PATIENTS†.1
Free trial offer for all eligible patients, regardless of benefit type‡
Covers up to a 30-packet supply of LOKELMA
Savings card for commercial patients§
Reduces eligible patients’ out-of-pocket costs to as low as $0 for up to 1 year
How the LOKELMA Savings Card works
Patients can begin saving with these 3 simple steps:
Have a prescription for LOKELMA.
Download a LOKELMA Savings Card.
You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription, or you are not insured and are responsible for the cost of your prescriptions. Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs or TriCare, and patients who are Medicare eligible and enrolled in an employer-sponsored group-waiver health plan or government-subsidized prescription drug benefit program for retirees. If you are enrolled in a state or federally funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient. This offer is not insurance, is restricted to residents of the United States and Puerto Rico, and to patients over 18 years of age.
Pharmacist Instructions for a Patient with an Eligible Third Party: For Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 8. This will reduce the eligible patient's out-of-pocket costs to as low as $0 for up to a 30-packet supply, subject to a maximum savings limit of $350 per 30-packet supply; patient out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.
Pharmacist Instructions for Insured/Not Covered Patients: Submit the claim to the primary Third-Party Payer first; if the primary claim submission shows a managed care restriction (step-edit, prior authorization or NDC block), continue the claim adjudication process and submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 3. This will reduce eligible patient's out-of-pocket costs to as low as $0 for up to a 30-packet supply, subject to a maximum savings limit of $350 per 30-packet supply; patient out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.
Pharmacist Instructions for a Cash-Paying Patient: Submit this claim to Change Healthcare. A valid Other Coverage Code (eg, 1) is required. The card will cover up to a maximum of $250 for up to a 30-packet supply. Reimbursement will be received from Change Healthcare. Valid Other Coverage Code Required. For any questions regarding Change Healthcare online processing, please call the Help Desk at .
My LOKELMA Support Program: helping patients access the care they need
Complete Suite of Access and Affordability Services
- Assistance with understanding patient insurance coverage
- Prior authorization, tier exception, and appeal process support
The program offers many benefits to those who are starting or already taking LOKELMA, including:
Assistance with understanding patient insurance coverage
Prior authorization, tier exception, and appeal process support
Scroll down for important support resources
Eligibility requirements and enrollment assistance with the LOKELMA Savings Card
Referrals to AZ&MeTM Prescription Savings Program, AstraZeneca’s patient assistance program
Information about independent charitable patient assistance foundations
For more information, please call the MY LOKELMA Support Program at
MY LOKELMA Support Program Enrollment Form & Appeal Resources
To get your patients started in the MY LOKELMA Support Program, download the Enrollment Form. Once completed, fax the form to .
For additional patient support, click below to access helpful templates and resources, including:
- Letter of Appeal
- Letter of Medical Necessity
- Tier Exception
- Formulary/Plan Exclusion Exception