How to Fill Out the SK Life Science Navigator Enrollment Form

The SK Life Science Navigator enrollment form is the single intake document that connects a patient prescribed XCOPRI (cenobamate) with benefits verification, copay assistance, free trial supply, and the manufacturer’s Patient Assistance Program. The prescriber fills out most of it; the patient supplies personal and insurance details and signs the HIPAA authorization. Completed forms go to the Navigator team by fax at 877-436-4188, by email at sknavigator@rxallcare.com, or through the electronic version linked by the QR code on the printed form. Questions go to 866-756-2844.¹

Gather These Items First

The form has four blocks, and each pulls from a different stack of documents. Pulling everything together before you open the PDF keeps the whole thing to one sitting.

A copy of the patient’s government-issued photo ID.
Front and back copies of every insurance card, primary and secondary.
Patient contact details: home phone, mobile, email, and language preference (English, Spanish, or other).
Caregiver name, phone, and relationship, if someone is authorized to speak for the patient.
The prescriber’s NPI, office address, specialty, and a direct office contact (usually the nurse or assistant who handles prior authorizations) with phone, fax, and email. If a PA or NP writes the prescription, the supervising physician’s name is also required.
Clinical history: diagnosis, prior anti-seizure medications tried, current medications, allergies, and other relevant conditions.
Confirmation that an e-prescription has gone to AllCare Plus Pharmacy (NCPDP 2243880, NPI 1902167596).¹

Filling Out Each Section

Patient Information

Enter the patient’s full legal name, date of birth, gender, and mailing address. Mark the language preference so the Navigator team assigns a matching coordinator. If insurance exists, check “Yes” and attach both sides of the card; repeat for secondary coverage if applicable.¹

Prescriber Information

List the NPI, office name, and full address. For the office contact, use a direct line rather than a main switchboard number. The Navigator team calls that person for clarifications and prior authorization follow-up, and a wrong number is where most delays start.

Diagnosis and Prescription

Indicate whether the patient is new to XCOPRI or already on it. Select the diagnosis (epilepsy or other) and list prior anti-seizure medications, current medications, allergies, and other conditions. This clinical snapshot is what the Navigator team uses to anticipate prior authorization and step therapy demands from the insurer.

Send the e-prescription to AllCare Plus Pharmacy before or at the same time you fax the enrollment form, and check the box on the form confirming that transmission.¹

Prescriber Attestation

The prescriber signs and dates the last section, certifying that a valid prescription is on file, that the patient has authorized disclosure of protected health information under 45 C.F.R. 164.508, and that any XCOPRI received through the program will be used solely by the named patient and will not be sold, traded, or billed to a government or commercial insurer. A missing signature or blank date is the single most common reason the Navigator team sends a form back.¹

How to Submit It

Three routes are open:

Fax the signed form, insurance card copies, and government ID to 877-436-4188. Keep the transmission confirmation.
Use the electronic version through the QR code printed on the form or the link on the SK Life Science Navigator website.
Email scanned documents to sknavigator@rxallcare.com.

Before sending, confirm that the prescriber signed and dated the attestation and that ID and insurance card copies are attached. Missing attachments trigger a callback that adds days.¹

What Happens Next

A coordinator verifies the patient’s benefits and checks whether XCOPRI is covered, which usually surfaces any prior authorization, step therapy, or formulary exception requirement. RxAssist lists a delivery timeline of zero to one week after a completed application is processed.² The Navigator team contacts both the patient and the prescriber’s office with the outcome. If the plan covers it, the coordinator coordinates with AllCare Plus Pharmacy to fill and ship. If the insurer wants more documentation, such as a letter of medical necessity, the coordinator calls the office contact listed on the form.

If the Insurer Denies Coverage

Denials are not unusual, especially when the plan requires other anti-seizure medications first. The Navigator program provides a templated Letter of Appeal that the prescriber’s office can customize and submit.³ Request the template or appeal help at 866-756-2844 or sknavigator@rxallcare.com. Clinical notes documenting which medications the patient has already tried, and why cenobamate is appropriate, make the appeal stronger.

Financial Programs the Form Unlocks

Which program applies depends on the patient’s insurance and income.

Free Trial Offer

Every eligible patient can receive the first 28-day supply of XCOPRI (the 12.5 mg/25 mg titration pack) at no cost, regardless of insurance status. Insurance is not billed. The offer is one-time use with no refills, and it is available in all U.S. states and Puerto Rico except Vermont.⁴ It is not meant to cover gaps or delays in insurance coverage; it exists so a new patient can start therapy while benefits verification runs.

Co-Pay Savings Card

Commercially insured patients 18 or older with a valid prescription may pay as little as $20 per month for refills past the trial period. The card cannot be combined with other manufacturer coupons or free trial offers, and it does not apply to prescriptions billed to Medicare, Medicaid, or any other government payer.⁴

Patient Assistance Program

The Patient Assistance Program (PAP) provides XCOPRI at no cost to patients who are uninsured, functionally uninsured, or facing financial hardship. Effective January 1, 2026, all applicants must have a pre-tax household income at or below 400% of the Federal Poverty Level. For a single-person household in the contiguous 48 states that threshold is $63,840 per year; for a family of four it is $132,000.⁵⁶

Every applicant must submit a complete 1040 tax form for each household member as proof of income. Patients whose household income falls below 150% of the Federal Poverty Level must also enroll in Medicare Extra Help and provide the approval or denial letter before the PAP application can move forward.⁵

Patients already enrolled in PAP as of December 31, 2025, whose household income falls between 401% and 500% of the Federal Poverty Level, keep a one-year grace period before the new 400% cap applies to them.⁵

1
RxAssist. SK Life Science Navigator Enrollment Form
2
RxAssist. SK Life Science Navigator
3
SK Life Science Navigator. SK Life Science Navigator – XCOPRI Treatment Support
4
XCOPRI. Savings and Resources
5
SK Life Science Navigator. Patient Assistance Program (PAP) Changes
6
U.S. Department of Health and Human Services. 2026 Poverty Guidelines