Reimbursement

If you are a patient or caregiver seeking commercial copay claim reimbursement, click the link below to access and download the Patient Copay Program Reimbursement form.
The form includes instructions on what supporting documentation is required to be submitted with your completed claim form to receive reimbursement, as well as guidance on how to submit your claim.

If you are a healthcare professional seeking commercial copay claim reimbursement, click on the link below to access and download the HCP Copay Program Reimbursement form.
The form includes instructions on what supporting documentation is required to be submitted with your completed claim form to receive reimbursement, as well as guidance on how to submit your claim.

A UB-04 or CMS 1500 may be substituted for the Healthcare Provider Reimbursement form, if preferred.