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Get started with enrollment
When you choose to enroll in Together with ZEJULA, you and your patient will have access to our Patient Experience Center and all that it offers. After enrollment, Together with ZEJULA can conduct benefit verifications, provide information about the prior authorization and appeal process, assess patient eligibility for the copay or patient assistance program, and offer specialty pharmacy triage and claims and billing support.
Help enroll your patients and/or their caregivers
Choose an option below
Start online or download and fax, whatever works best for you.
Complete and sign
Sign as marked or provide your digital signature.
Review and submit
Make sure all required fields are completed by you and your patient.
Digital e-Enrollment
You can begin your patient’s electronic enrollment into Together with ZEJULA. This process should take approximately 5 to 10 minutes and will easily guide you through what information is needed.
Please make sure the patient provides their email address, insurance information, and any other required information.
Other options to enroll
Prefer a paper form?
You can download and print the enrollment form with your patient. After you complete and sign the form, you will need to fax it to Together with ZEJULA at 833-ZEJULA0 (833-935-8520) to start the process.
FOR COST SUPPORT ONLY
Only interested in copay support? We’ve got you covered.
If you have all the other details covered and your patients are interested only in cost support, you can get the process started. Use the Together with ZEJULA Copay Program to easily have your eligible commercially insured patients consent and receive a virtual copay card.
If eligible and approved, your patient will receive an email for their consent to the program requirements. Once complete, eligible patients will receive their unique copay member information. Restrictions apply.
Frequently asked questions
We are here to help!
You can reach your Patient Navigator at 1-844-4GSK-ONC (1-844-447-5662).
Monday–Friday: 8 AM–8 PM ET