One form to get support with Orilissa® Complete

Give your clinically appropriate patients a free 28-day trial* of ORILISSA with Orilissa Complete

Help her enroll in Orilissa Complete to activate her free trial:

Orilissa® Complete patient financial support

1 Fill out

Download and complete this

with your patient to access a 28-day trial supply, so she has the opportunity to try treatment for free.* Then, you can both decide if continuing ORILISSA is still the right choice for her.

2 Fax

Fax the form to 1-833-674-5477.

An Orilissa Complete Access Specialist will contact your office with next steps.

3 She's enrolled!

Give your patient the Patient Welcome Sheet.

Starting your patient on the free trial? We’ll call to confirm shipping details.

Help your patients get the support they need with Orilissa Complete

Download the Orilissa Complete Enrollment & Prescription Form OR for any enrollment questions call 1-800-ORILISSA

Savings and access support

One form gives your clinically appropriate patients access to everything Orilissa Complete has to offer:

Orilissa® Complete Savings Card Icon

Start your patients on their first prescription for free

Once enrolled, a free 28-day trial supply of ORILISSA will be shipped quickly, directly to her. Then, you can both decide if continuing on ORILISSA is still the right choice for her.

Orilissa® Complete Savings Card Icon

Orilissa Complete Savings Card

The Orilissa Complete Savings Card can help your eligible, commercially insured patients pay as little as $5 per month†  for ORILISSA.

Orilissa® Complete Access Specialist Icon

 Dedicated Access Specialists

Access Specialists are an in-person and over-the-phone resource with expertise in options to consider based on each patient’s unique insurance coverage situation.

  • They can educate on payer prior authorization (PA) and appeal processes so you can determine the best access solution
  • They are a resource with expertise in insurance plan processes at a national, local, and program level

For questions about the free trial,* prior authorizations, or anything related to insurance, call Orilissa Complete at 1-800-ORILISSA 

Access forms

Orilissa Complete is here to help your patients get timely access to ORILISSA. Along with requesting information from an Orilissa Complete Access Specialist, you can download the forms your patients may need to get started.

Instructions are available to provide helpful tips and guidelines for completing the forms.

Prior Authorization Brochure

Prior Authorization Instructions

Prior Authorization Tracker

Prior Authorization Tracker Template

Appeal Letter PDF

Appeal Letter Sample Template

Letter of Medical Necessity PDF

Letter of Medical Necessity Sample Template

This information is for informational purposes only and is not intended to provide reimbursement or legal advice. The information presented here does not guarantee payment or coverage.

For questions about the free trial,* prior authorizations, or anything related to insurance, call Orilissa Complete at 1-800-ORILISSA 

*The ORILISSA free trial provides a single 28-day trial supply of ORILISSA at no cost to new patients residing in the United States with a valid prescription for an FDA-approved indication of ORILISSA and who enroll in Orilissa Complete. The trial is intended solely to allow new patients not currently taking ORILISSA to determine with their healthcare provider whether ORILISSA is right for them. There is no obligation to continue use of ORILISSA after the trial has concluded and this program does not guarantee insurance coverage. Eligible patients are limited to one 28-day trial supply and may not re-enroll. The ORILISSA trial supply will be dispensed only through an AbbVie-authorized pharmacy to the patient’s home address and may not be sold or further distributed. No claims for payment may be submitted to any third party insurance plan for product dispensed by program. AbbVie reserves the right to change or discontinue the trial at any time without notice. The trial is not health insurance and is not a discount, coupon, rebate or financial assistance program. Limitations may apply.

Terms and Conditions apply. This benefit covers ORILISSA. Eligibility: Available to patients with commercial prescription insurance coverage for ORILISSA who meet eligibility criteria. Copay assistance program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use the Orilissa Complete Savings Card and patient must call Orilissa Complete at 1-800-ORILISSA (1-800-674-5477) and stop use of the copay card. Patients residing in or receiving treatment in certain states may not be eligible. Patients may not seek reimbursement for value received from Orilissa Complete including the copay card from any third-party payers. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.