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