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THIS SECTION IS FOR HEALTHCARE PROFESSIONALS (HCPs) ONLY

Healthcare Professionals can download a paper application here

To help you get started, please view our short video that will walk you through how to apply and what to expect from the process.

https://vimeo.com/1092710352

Prefer to fax in an application for your patient?

Just follow these 3 simple steps:

1

Download and print the application

2

Collect all required documentation from your patient

3

Fax the application and the documentation to OPAF at 1-844-727-6274

Please note: Faxed applications are processed within 5 business days. If this is a time-sensitive request, please submit an application online.

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Enrollment Application for ABILIFY MAINTENA® (aripiprazole) extended-release injectable suspension

/content/dam/otsukapatientassistance/live-assets/patient-forms/PAUS25EBP0013-OPAF-ABILIFY-MAINTENA-Enrollment-Form-2025.pdf

Download

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Enrollment Application for ABILIFY ASIMTUFII® (aripiprazole) extended-release injectable suspension

/content/dam/otsukapatientassistance/live-assets/patient-forms/PAUS25EBP0016-OPAF-ABILIFY-ASIMTUFII-Enrollment-Form-2025.pdf

Download

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Enrollment Application for REXULTI® (brexpiprazole) tablets

/content/dam/otsukapatientassistance/live-assets/patient-forms/PAUS25EBP0014-OPAF-REXULTI-Enrollment-Form-2025.pdf

Download

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Enrollment Application for NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) capsules

/content/dam/otsukapatientassistance/live-assets/patient-forms/PAUS25EBP0015-OPAF-NUEDEXTA-Enrollment-Form-2025-APPROVED.pdf

Download

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Enrollment Application for VOYXACT® (sibeprenlimab-szsi) injection

/content/dam/otsukapatientassistance/live-assets/patient-forms/VOYXACT%20Enrollment%20Form.pdf

Download

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Enrollment Application for JYNARQUE® (tolvaptan) tablets

/content/dam/otsukapatientassistance/live-assets/patient-forms/JYNARQUE%20Enrollment%20Form.pdf

Download

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See GLOBAL FULL PRESCRIBING INFORMATION for NUEDEXTA and VOYXACT.
See U.S. FULL PRESCRIBING INFORMATION, including BOXED WARNING for ABILIFY MAINTENA, ABILIFY ASIMTUFII, JYNARQUE, and REXULTI.
See MEDICATION GUIDES for ABILIFY MAINTENA, ABILIFY ASIMTUFII, JYNARQUE, and REXULTI.

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OPAF Care Connect Benefits

Prefer to apply online on behalf of your patients? Utilize the OPAF Care Connect Prescriber Portal.

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Receive eligbility determination within 2 business days
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Use your work space to find your application and more
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Email patient eConsent and HCP eSignature for a seamless application process
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View your application online
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Get up-to-date and timely notifications
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Stay informed with email notifications for patient applications and product requests:

  • Get updates regarding your application status and determination results
  • Receive notifications when it’s time for annual re-enrollment
  • Track status of product shipments
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