How to Fill Out the Dupixent MyWay Medicare Part D Re-Enrollment Form

The Dupixent MyWay enrollment form is the five-page document you and your prescriber complete together to start Sanofi and Regeneron’s patient support program, which investigates your insurance, arranges copay or free-drug assistance if you qualify, and ships Dupixent through a specialty pharmacy. With a list price of $4,193.03 per carton as of January 2026, most patients need this program to afford the medication.¹ Your doctor’s office handles the clinical sections, you handle the personal and insurance sections, and the program takes it from there.

Who Can Enroll

You can enroll if you live in the 50 states, the District of Columbia, Puerto Rico, Guam, or the U.S. Virgin Islands and a licensed prescriber has written you a Dupixent prescription for an FDA-approved condition.¹ Each approved indication has its own minimum age, and your prescriber certifies the diagnosis on the form:

Atopic dermatitis (moderate-to-severe): 6 months and older
Asthma (add-on maintenance, eosinophilic phenotype or oral corticosteroid-dependent): 6 years and older
Chronic rhinosinusitis with nasal polyps: 12 years and older
Eosinophilic esophagitis: 1 year and older, weighing at least 15 kg
Chronic spontaneous urticaria: 2 years and older
Allergic fungal rhinosinusitis: 6 years and older, with a history of sinus surgery
Prurigo nodularis: adults 18 and older
Bullous pemphigoid: adults 18 and older
Chronic obstructive pulmonary disease (eosinophilic phenotype): adults 18 and older

What kind of help you can get depends on your coverage. If you have commercial insurance, including marketplace, federal employee, or state employee plans, you may qualify for the Dupixent MyWay Copay Card, which can bring your out-of-pocket cost to as little as $0 per fill up to a per-patient annual maximum. Once you hit that cap in a calendar year, remaining costs are yours.¹

The copay card is not available if any part of your prescription is paid for by Medicare, Medicaid, VA, Department of Defense, TRICARE, or any other federal or state program, including state pharmaceutical assistance programs.¹ You can still enroll in Dupixent MyWay for the benefits investigation and specialty pharmacy coordination; the financial assistance piece is simply off the table.

If you have no insurance or a plan that doesn’t cover Dupixent at all, you may qualify for the Sanofi Patient Connection program, which provides the medication at no cost. The income cutoff is household income at or below 400% of the Federal Poverty Level.² For 2026, that works out to about $63,840 for a single person and $132,000 for a family of four.³

Getting the Right Version of the Form

There is a separate enrollment form for each approved indication, and each one has a diagnosis section tailored to that condition’s ICD-10 codes. Your doctor’s office may already have the right form; if not, download it from the Dupixent HCP enrollment page. Condition-specific versions exist for atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis, prurigo nodularis, bullous pemphigoid, chronic obstructive pulmonary disease, chronic spontaneous urticaria, and allergic fungal rhinosinusitis.⁴ Forms are available in English and Spanish.⁵ Using the wrong indication’s form won’t necessarily disqualify you, but it slows processing because the diagnosis section won’t line up with your condition.

Prescribers can skip the paper form entirely by ePrescribing directly to the Dupixent MyWay Pharmacy (NPI: 1902780729, NCPDP: 5945879). The clinical and prescription details transmit electronically, but you still need to sign the patient authorization sections.⁴

What You Fill In

Section 1 asks for your full name, date of birth, gender, preferred language if not English, home address (no P.O. boxes), email, and phone numbers. The form does not ask for your Social Security number.⁶ Attach copies of the front and back of every insurance card you have — medical and pharmacy, primary and secondary.

The insurance detail fields matter more than almost anything else on the form. The program will ask for your primary and secondary insurance policy numbers and your Pharmacy Benefit Manager information. If a group number is wrong or a BIN number is missing from your pharmacy card, the benefits investigation stalls until someone calls you to clear it up. Copy these fields straight from the cards rather than from memory.

Near the end, you sign the patient authorization. That signature lets Dupixent MyWay, Sanofi, Regeneron, and their agents share your health information with your insurer, the specialty pharmacy, and your doctor’s office so the program can actually do its work.⁶ Without it, nothing happens on your case. Read the full language before signing so you know what you’re consenting to share and with whom.

What Your Prescriber Fills In

Your doctor completes sections 2 through 5: name, National Provider Identifier, office address, phone, and fax, plus the diagnosis with an ICD-10 code and the prescribed dose and injection frequency. They then sign the prescriber certification, which confirms you are their patient, that the information is accurate, and that Dupixent is medically necessary for an FDA-approved indication.⁶ This section also attests that the prescriber obtained your written HIPAA authorization. A form missing either signature — yours or the prescriber’s — cannot be processed.

How to Submit

You have two submission options:

Fax all five pages plus insurance card copies to 1-844-387-9370.
Upload the form as a PDF or clear image at DUPIXENTMyWayPortal.com using access code 8443879370.

There is no mailing address listed for paper submissions.⁴ Whichever route you use, confirm every page is included and every signature is visible before you send. A partial upload is treated the same as an incomplete form — it sits until someone calls to fix it.

After You Submit

Dupixent MyWay assigns a Case Manager to your file. You can reach the program at 1-844-DUPIXENT (1-844-387-4936), option 1, Monday through Friday, 8 AM to 9 PM Eastern.⁷ The program runs a benefits investigation to determine your out-of-pocket costs and copay assistance eligibility, sends your prescriber a summary of benefits, and routes the prescription to the payer-preferred specialty pharmacy.⁴

Most insurers require prior authorization before covering Dupixent, and your Case Manager works with your doctor’s office to get through it. Dupixent is dispensed only through specialty pharmacies, not retail, so once authorization clears, the specialty pharmacy contacts you to arrange delivery to your home or your doctor’s office.⁸

Dupixent is self-injected, and the program includes a Nurse Educator who can walk you through your first injection in person, by video, or over the phone, separate from the training your doctor’s office provides.⁹ Your Case Manager stays with you through treatment to coordinate refills and handle insurance changes. If your coverage shifts mid-year, let Dupixent MyWay know so they can re-run the benefits investigation.

Copay card and patient assistance benefits are generally approved in one-year periods. When your enrollment year ends, you’ll go through a renewal that requires updated financial documentation and a current prescription. The program should reach out as your anniversary approaches, but calling 1-844-DUPIXENT ahead of that date is the surest way to avoid a gap in deliveries.

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