Can't upload documents? No problem! You can also submit your claim in the following ways:

P.O. Box 6875
Bridgewater, NJ 08807

(877) 847-3291

Send a copy of your receipt plus a cover page with your full name and contact information, or download submission form for fax or mail to help make sure you include all the necessary information.

Co-Pay Assistance Claim Forms for Mail or Fax

Co-Pay Assistance Claim Form for Elelyso, ELREXFIO, Inflectra, Nivestym, Nyvepria, Ruxience, Trazimera, Zirabev

Use the Co-Pay Assistance Claim Form if you paid out of pocket.

Co-Pay Assistance Request Form for BEQVEZ

Use the Co-Pay Assistance Request Form if you paid out of pocket.

For any assistance please contact Patient Support.

(800) 555-4820
8:00 AM-8:00 PM ET Mon-Fri