Programs to help you get RUBRACA

QuickStart Program*

Helps you start RUBRACA if you experience coverage delays regardless of income or insurance. If eligible, you may receive RUBRACA in 15-day increments for up to 60 days (2 months) while coverage is pending or until alternate funding resources have been identified and approved.

Coverage Link Program*

Provides RUBRACA in 15-day increments (up to 90 days) if you are eligible and experiencing a change in commercial insurance status. This includes switching to a new insurer following a job change or switching plans during an employer’s annual enrollment period.

RUBRACA Co-Pay Assistance Program*

Pay as little as $0 if you’re an eligible patient with private or commercial insurance who has been prescribed RUBRACA.

Patient Assistance Program (PAP)*

Available if you are eligible and are uninsured or cannot afford medication.

*Terms & Conditions may apply.

Complete the RUBRACA Enrollment and Comprehensive Support Form

If you’ve been prescribed RUBRACA, you may want to consider enrolling in one of the assistance programs offered. These programs can help you access RUBRACA through coverage, co-pay assistance, and ongoing support throughout treatment.

There are 2 options to get started:

Enroll online

Complete the form, provide your consent, and access your information (including co-pay ID) all in one secure place.

Start online enrollment
Download and fax the form
Prefer a paper form? Download and complete the following, then fax it to 1-844-779-7717.
Download the enrollment form
The enrollment form is not a prescription. Your doctor will need to submit your prescription separately.
After you’re enrolled, a pharma& case manager will follow up to walk you through your benefits, coverage details, and next steps for your treatment.

TERMS & CONDITIONS FOR THE pharma& QUICKSTART PROGRAM


Eligibility Criteria

  • RUBRACA (rucaparib) must be prescribed on-label by an appropriately licensed health care professional (HCP), and the HCP must certify that based on his/her independent medical judgment, RUBRACA is a medically appropriate treatment option for the patient
  • Patient must have either commercial or government insurance
  • Patient must reside in the US or US Territories and be 18 years old or older
  • Patient must be new to RUBRACA treatment – existing RUBRACA patients are not eligible
  • Patient must request a coverage determination from their insurer and must experience a coverage delay of more than 5 days
Terms & Conditions
  • Patient may be eligible for free RUBRACA for up to 60 days of therapy. Quick Start product will end the earlier of (1) the patient receiving a coverage determination, or (2) 60 days
  • Not available to uninsured patients
  • Patients and participating prescribers agree not to seek reimbursement for all, or any, part of the benefit
  • Product will be shipped approximately every 15 days
  • Patients are eligible for Quick Start once per lifetime
  • This program is not health insurance. This program may not be combined with any other financial assistance program, free trial, discount, rebate, coupon, or other offer
  • pharma& reserves the right to make eligibility determinations and to rescind, revoke, or amend the program and discontinue support at any time without notice

TERMS & CONDITIONS FOR THE pharma& COVERAGE LINK BRIDGE PROGRAM

Eligibility Criteria

  • RUBRACA (rucaparib) must be prescribed on-label by an appropriately licensed health care professional (HCP), and the HCP must certify that based on his/her independent medical judgment, RUBRACA is a medically appropriate treatment option for the patient
  • Patient must have either commercial or government insurance
  • Patient must reside in the US or US Territories and be 18 years old or older
  • Patient must be an existing RUBRACA patient who has had a change in insurance and is experiencing a delay in obtaining insurance coverage from their new insurer
  • Patient must request a coverage determination from their new insurer and must experience a coverage delay of more than 5 days
Terms & Conditions
  • Patient may be eligible for free RUBRACA for up to 60 days of therapy. Coverage Link product will end the earlier of (1) the patient receiving a coverage determination, or (2) 60 days
  • Not available to uninsured patients
  • Patients and participating prescribers agree not to seek reimbursement for all, or any, part of the benefit
  • Product will be shipped approximately every 15 days
  • This program is not health insurance. This program may not be combined with any other financial assistance program, free trial, discount, rebate, coupon, or other offer
  • pharma& reserves the right to make eligibility determinations and to rescind, revoke, or amend the program and discontinue support at any time without notice

TERMS & CONDITIONS FOR THE pharma& CO-PAY PROGRAM

Patient Instructions 

If you are an eligible, commercially insured patient, the RUBRACA co-pay card will reduce your out-of-pocket costs up to the copay program annual limitation. If you reach the maximum annual limit, you will be responsible for any additional cost.

When you use this card, you are certifying that you understand and agree to comply with the program Terms & Conditions below.

Terms & Conditions

  • This offer is only available to patients with commercial insurance. The program is not available for patients who receive reimbursement under any federal, state or government-funded insurance programs, including patients who: (i) are enrolled in Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program; (ii) are not using insurance coverage at all; (iii) are enrolled in an insurance plan that reimburses for the entire cost of the drug; or (iv) where product is not covered by patient’s insurance
  • The value of this program is exclusively for the benefit of patients and is intended to be credited toward patient out-of-pocket obligations, including applicable copayments, coinsurance, and deductibles
  • Co-pay maximizers are programs in which the amount of your out-of-pocket costs is increased to reflect the availability of support offered by a manufacturer assistance program. Except where prohibited by applicable state law, if your insurance company or health plan implements either an accumulator adjustment or co-pay maximizer program, you will not be eligible for, and agree not to use, co-pay assistance because these programs are inconsistent with our agreed intent that this program is solely for your benefit. You also agree that you are personally responsible for paying any amount of co-pay required after the savings card is applied. Any out-of-pocket costs remaining after the application of the savings card may not be paid by your health plan, pharmacy benefit programs, or any other program
  • If you learn your insurance company or health plan has implemented either an accumulator adjustment program or a co-pay maximizer program, you agree to inform pharma& of this fact by calling 1-844-779-7707 to discuss alternative options that may be available to support you. Since you may be unaware whether you are subject to a co-pay maximizer program when you enroll in the copay assistance program, pharma& will monitor program utilization data and reserves the right to discontinue co-pay assistance at any time if pharma& determines that you are subject to a co-pay maximizer program. If your health plan removes RUBRACA from a co-pay maximizer program, you will return to eligibility for co-pay assistance up to the maximum annual benefit
  • Proof of purchase may be required
  • Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account
  • Patient is responsible for complying with any applicable limitations and requirements of his/her health plan related to the use of the program. The program may not be used if prohibited by a patient’s health insurer
  • Program is not valid where prohibited by law. Valid only in the United States and US Territories: American Samoa, Guam, Northern Mariana Island, Puerto Rico and US Virgin Islands
  • This program is not health insurance. This program may not be combined with any other financial assistance program, free trial, discount, rebate, coupon, or other offer
  • pharma& reserves the right to make eligibility determinations and to rescind, revoke, or amend the program and discontinue support at any time without notice
  • For complete information about the terms & conditions of this program, including the limitations on use and the amount of assistance, call 844-779-7707

TERMS & CONDITIONS FOR THE pharma& PATIENT ASSISTANCE PROGRAM

Eligibility Criteria

  • RUBRACA (rucaparib) must be prescribed on-label by an appropriately licensed health care professional (HCP), and the HCP must certify that based on his/her independent medical judgment, RUBRACA is a medically appropriate treatment option for the patient
  • Patient must be either uninsured or insured without coverage for RUBRACA after completing any available appeals process
  • Patient must reside in the US or US Territories and be 18 years old or older
  • Patient must have gross annual household income at or below 300% of the current Federal Poverty Level (FPL) (FPL Guidelines available at https://aspe.hhs.gov/poverty-guidelines). Below are the 300% 2024 FPL limits based on household size:
Household Size Annual Income*
1 $45,180 or less
2 $61,320 or less
3 $77,460 or less
4 $93,600 or less
If your household has more than four members, please add $16,140* for each additional dependent member.
*Subject to change in 2025, as the FPL is updated annually by the U.S. government.

Terms & Conditions

  • Patient may be asked to submit documentation (e.g., federal tax returns; IRS forms such as W-2, 1099, 4506T; Social Security statement/checks/benefit letter; pension or disability benefit statement/letter; unemployment compensation statement; pay stubs) to validate levels of income
  • pharma& will review all submitted documentation, including the pharma& Patient Assistance Program eligibility form and all substantiating information, prior to approving a patient for eligibility under the pharma& Patient Assistance Program
  • Both the patient and prescriber must sign and date all submitted documentation to attest to the accuracy of the information
  • Uninsured patients, commercially insured patients, and federal healthcare program beneficiaries who qualify for the pharma& Patient Assistance Program are enrolled for the entire calendar year. However, pharma& reserves the right to reassess eligibility for uninsured patients and patients with commercial insurance during the calendar year
  • The pharma& Patient Assistance Program is not insurance
  • Provision of free product under this program is not contingent upon future purchase or prescribing of RUBRACA
  • No patient, pharmacy, payer, or other third party may be billed for the free product provided through the pharma& Patient Assistance Program
  • Patients and providers agree not to submit any claims for reimbursement for all or any part of the free product provided through the pharma& Patient Assistance Program. If the HCP or pharmacy receives any payments for products provided under this program, they agree to return such payments to the applicable payer or patient
  • Patient, pharmacist, and prescriber agree to not sell, purchase, trade, or offer to sell, purchase, or trade any free product received through the pharma& Patient Assistance Program
  • Patient cannot apply the value of the free product received through the pharma& Patient Assistance Program toward any insurance benefit out-of-pocket spending calculations
  • pharma& retains the right to make the final decision regarding any pharma& Patient Assistance Program product request. All product requests are subject to review at pharma&’s sole discretion, and all decisions by pharma& are final
  • pharma& requires that you re-apply every year
  • pharma& reserves the right to modify or revoke this program at any time without notice

These Terms & Conditions are effective as of 01/01/2025.

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IMPORTANT SAFETY INFORMATION

What is RUBRACA used for?

RUBRACA tablets are a prescription medicine used in adults for:

  • The treatment of castration-resistant prostate cancer (prostate cancer that no longer responds to medical or surgical treatment that lowers testosterone):
    • That has spread to other parts of the body (metastatic), and
    • Has a certain type of inherited (germline) or acquired (somatic) abnormal BRCA gene, and you have been treated with certain medicines for your cancer.
  • Your healthcare provider will perform a test to make sure RUBRACA is right for you.
It is not known if RUBRACA is safe and effective in children.

What Warnings should you know about RUBRACA?

RUBRACA tablets may cause serious side effects including: Bone marrow problems called Myelodysplastic Syndrome (MDS) or a type of cancer of the blood called Acute Myeloid Leukemia (AML). Some people who have cancer and who have received previous treatment with chemotherapy or certain other medicines for their cancer have developed MDS or AML during or after treatment with RUBRACA. MDS or AML may lead to death. If you develop MDS or AML, your healthcare provider will stop treatment with RUBRACA. Symptoms may include weakness, weight loss, fever, frequent infections, blood in urine or stool, shortness of breath, feeling very tired, bruising or bleeding more easily. Symptoms of low blood cell counts are common during treatment with RUBRACA, but can be a sign of serious problems, including MDS or AML.

Before you take RUBRACA, tell your healthcare provider about all of your medical conditions, including if you are a male with a female partner who is pregnant or able to become pregnant, effective birth control should be used during treatment and for 3 months after the last dose of RUBRACA. Do not donate sperm during use and for 3 months after the last dose of RUBRACA. 

What other important information should I know about RUBRACA?

Your healthcare provider will do blood tests before and every month during treatment with RUBRACA to monitor your blood cell counts. Weekly blood tests will be performed if you have low blood cell counts for a long time. Your healthcare provider may stop treatment with RUBRACA until your blood cell counts improve.

Avoid spending time in sunlight while on RUBRACA since your skin may become more sensitive to the sun and may sunburn more easily. You should wear a hat and clothes that cover your skin and use sunscreen to help protect against sunburn if you have to be in the sunlight.

What are the side effects of RUBRACA?

The most common side effects of RUBRACA in people with prostate cancer include: Tiredness or weakness, nausea, decrease in hemoglobin (anemia), changes in liver function tests, decreased appetite, rash, constipation, low blood cell counts, vomiting, and diarrhea. These are not all the possible side effects of RUBRACA. Call your healthcare provider for medical advice about side effects.

What other medications might interact with RUBRACA?

RUBRACA can increase the amounts of other medications you may be taking, which can increase the risk of side effects. Tell your healthcare provider about all your medical conditions and all medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

You may report side effects to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. You may also report side effects to pharma& at 1-800-506-8501.
This information is not comprehensive.
How to get more information:
  • Talk to your health care provider or pharmacist.
Please see full Prescribing Information for RUBRACA.

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