Patient Forms

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

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

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Enrollment Application for REXULTI^® (brexpiprazole) tablets

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

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Enrollment Application for SAMSCA^® (tolvaptan) tablets

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Enrollment Application for JYNARQUE^® (tolvaptan) tablets

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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.

Supported Medications

OPAF provides eligible patients no-cost support for the following prescribed medications:

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

To report SUSPECTED ADVERSE REACTIONS, contact Otsuka America Pharmaceutical, Inc. at
1-800-438-9927 or FDA at 1-800-FDA-1088 (www.fda.gov/medwatch).

Otsuka America Pharmaceutical, Inc. does not control or influence how Otsuka Patient Assistance Foundation, Inc. distributes funds.

Secure messaging ensures patient privacy because it is a HIPAA-compliant, password-protected electronic messaging platform. You can communicate directly with an OPAF Patient Access Advocate without having to pick up the phone. Through the platform you can securely send electronic messages with any questions, communications, and documents at your convenience.

Because it is HIPAA-compliant, there is a one-time account activation process. The activation process takes less than 3 minutes. Once your account is active, you can send messages to OPAF immediately.

To setup your OPAF secure message account follow the steps below:

Click on the (button or envelope) below to start the process
The system will prompt you to enter your email address as a "New to SecureContact"
A verification email will be sent to the email address that you entered
In your email inbox, you will find a message from "[email protected]"
Open this message and click on the link to activate your account
Complete the account activation by creating a password
Your account is active, and you can securely send a message to OPAF

If you have any questions, please contact OPAF at 1-855-727-6274 8am - 6pm ET.

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