Fill this form out to allow Access 360 to provide assistance for your LOKELMA prescription. Available in English and Spanish. The Access 360 General Patient Authorization Form must be signed for you to utilize Access 360 support.
Click here to fill out the form online.
A multi-page enrollment form to capture necessary patient, provider, and prescription information to start a new request for support.
This brochure provides information about LOKELMA affordability options.