Downloadable Resources

HCP offices should fill out a Navigator enrollment form to get their patient started.

English   |   Spanish

This simple enrollment form will be used as a patient’s first prescription. Have the patient sign the Patient Authorization section while at the office.

Downloadable Resources

Patient Assistance Program Enrollment Form

English   |   Spanish

Fill out this enrollment form for patients who may need access to the Patient Assistance Program.

Downloadable Resources

Letter of Medical Necessity

This is a templated Letter of Medical Necessity for office staff to fill out and provide to insurers.

Downloadable Resources

Letter of Appeal

For patients who have been denied coverage for XCOPRI^® (cenobamate tablets) CV, office staff may use this templated Letter of Appeal to advocate for coverage.

Downloadable Resources

Medicare Part D Tier Exception Letter

For Medicare Part D patients that have a high copay for their XCOPRI^® (cenobomate tablets) CV, office staff are able to use this template to write a Medicare Tier Exception Letter which may make their copay more affordable.

Downloadable Resources

Low Income Subsidy/Extra Help Information

This is a one-page document that will provide offices and patients information about Medicare Low Income Subsidy/Extra Help program and how to apply.