Where Can I Send an ORMALVI (Dichlorphenamide) Tablets Prescription?

Once you have completed the ORMALVI enrollment form, you need to send it to our product support platform, Cycle Vita™, where our expert team will take care of all the details so your patients can get started on their dichlorphenamide treatment as soon as possible. This is the only way you can enroll a patient onto ORMALVI.

You can either:

  • 2. Fax it to + 1 (888) 385-8482

Please use the enrollment form on the ORMALVI website and remember to specify dispense as written (DAW) on every enrollment form, new or refill, to ensure that your patients receive ORMALVI and the support available through Cycle Vita.

Sending your own prescription can cause delays or could mean a Specialty Pharmacy may give a patient another dichlorphenamide instead. This would mean your patients will not be able to access Cycle Vita, which can provide eligible* patients with:

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Bridge Program*: A free supply of ORMALVI that allows diagnosed patients to begin therapy immediately while Cycle Vita secures appropriate Benefit Verification and Prior Authorization. The Bridge Program may also be requested for existing patients who are temporarily experiencing disruption in therapy due to insurance coverage.

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Co-pay Assistance Program*: On ORMALVI, commercially insured eligible patients may pay as little as $0.

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Hub Support: Including financial and logistics.

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Continuous Clinical Product Support: Cycle Vita provides patients with product support to help manage every aspect of the ORMALVI therapeutic routine, such as clinical education and onboarding onto dichlorphenamide.

Once we have received your enrollment form, the Cycle Vita team will direct them to the correct Specialty Pharmacy.

ORMALVI has a limited distribution. If your patients are contacted by someone who is not from Cycle Vita or their Specialty Pharmacy, please let us know at + 1 (888) 385-8482 or hello@cyclevita.com.

To ensure faster turnaround times for you and your patients, please see our Rx Checklist to make sure you include everything required for a quick process.

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References

*Some areas of support may not be accessible to all patients. Eligibility criteria may apply to ensure compliance with all applicable federal and state requirements, and benefits may be limited to commercially insured patients only. For more detailed information about eligibility, terms and conditions, please contact the Cycle Vita team at +1 (888) 360-8482.