Access 360 General Patient Authorization Form (PAF)

Find the right resources to assist your LOKELMA patients

LOKELMA Enrollment Form

LOKELMA Enrollment Form

A multi-page enrollment form to capture necessary patient, provider, and clinical information to start a new request for support.

LOKELMA Overview of Key Steps

LOKELMA Overview of Key Steps

A single-page overview of the key steps for obtaining LOKELMA.

LOKELMA Access & Coverage Management Guide

LOKELMA Access & Coverage Management Guide

This guide provides an overview of the support offerings for LOKELMA, and outlines how we can help to ease the access process for your patients.

LOKELMA Savings Program & Affordability Brochure

LOKELMA Savings Program & Affordability Brochure

A resource describing ways in which patients can pay for LOKELMA if it is approved or denied.

LOKELMA Prior Authorization & Appeal Checklist

LOKELMA Prior Authorization & Appeal Checklist

Checklists designed to be used as a reference during the prior authorization (PA) and denial/appeal processes for LOKELMA.

LOKELMA Support Program Overview

LOKELMA Support Program Overview

A quick reference for understanding the offerings provided for LOKELMA.

LOKELMA Sample Letter of Medical Necessity

LOKELMA Sample Letter of Medical Necessity

This template is offered as a resource a healthcare provider could use when responding to a request from a patient’s insurance company to provide a letter of medical necessity for prescribing LOKELMA.

LOKELMA Sample Letter of Appeal

LOKELMA Sample Letter of Appeal

This template is a sample resource a healthcare provider could use when responding to a request from a patient's insurance company to provide a letter of medical necessity for prescribing LOKELMA.

LOKELMA Sample Letter of Tier Exception

LOKELMA Sample Letter of Tier Exception

This template is offered as a resource a healthcare provider could use when requesting a Tier Exception from a patient’s health benefits company when LOKELMA is non-preferred.

LOKELMA Sample Letter of Formulary/Plan Exclusion Exception

LOKELMA Sample Letter of Formulary/Plan Exclusion Exception

Use this template when requesting an Exception for a Formulary/Plan Exclusion for LOKELMA for one or more of the following reasons:

  • LOKELMA is not on the plan’s list of covered drugs
  • LOKELMA was previously included on the plan’s list of covered drugs, but is being removed or was removed from this list during the plan year
  • To request an exception to the requirement that the patient try another drug before the patient is able to get LOKELMA as the healthcare provider has prescribed