SyndAccess Patient Enrollment
Complete enrollment in just 3 simple steps:
- Type the information directly into the fields on the PDF. Save the file and print it out,
- Certify healthcare professional and patient consent with signatures.
- Fax the completed form to SyndAccess at 1-888-567-3299.
OR
Print it out and manually write in the information.
All pages, including signature pages, should be submitted to allow for processing. SyndAccess may require additional documentation to assess program availability.
Copay Program Enrollment
For eligible, commercially insured patients who cannot afford their Syndax medication.
With the Revuforj® (revumenib) Copay Program, eligible patients with commercial insurance may pay as little as $0 per prescription.*†
Click the button below to enroll your patient. You will be redirected to the Copay Program website where you will be asked to answer eligibility questions and confirm the terms and conditions.
Please see Full Prescribing Information, including BOXED WARNING.
For processing or program questions, please call
1-888-567-SYND
(1-888-567-7963),
Monday-Friday, 9 AM to 6 PM ET
- Excludes cash-paying patients, Medicare Part A, B, C, or D, Medicaid, TRICARE, VA, DoD, or any other federal or state healthcare programs. Maximum benefits may apply. Must include a valid prescription for an FDA-approved indication in accordance with the Prescribing Information.
- All SyndAccess programs are subject to eligibility requirements and changes. Criteria above do not represent all criteria for each program. Must be a US resident or US territory resident with a valid prescription. Restrictions apply. See full terms and conditions.
Patient Services Team
After enrollment in SyndAccess, our patient services team can work directly with your patients and/or their caregivers and may help support access, affordability, and adherence to treatment.