All applicable information is required to receive a direct reimbursement payment. Not all patients are eligible for a Reimbursement. This Reimbursement Form registration will be processed by McKesson Corporation (McKesson), ViiVConnect Copay Program's administrator.
Instructions for Completing the Reimbursement Form:
  1. Please review the full Eligibility Requirements and Restrictions of the ViiVConnect Copay Program to confirm eligibility. Patients must be eligible for the ViiVConnect Copay Program, consistent with the ViiVConnect Copay Program Terms and Conditions, to receive a direct reimbursement payment. If you have questions about direct reimbursement payment for the product for which you have paid out of pocket, please call this toll-free number: 866-747-1170.
  2. If the product was purchased from a retail or mail-order pharmacy, and the pharmacy did not accept the ViiVConnect Copay Program, complete this Reimbursement Form legibly and completely, including completing the applicable certifications on the following pages. You must be 18 years of age or older and a resident of the United States and Puerto Rico to request a direct Reimbursement Payment.
  3. Claims covered by any state or federally funded programs, including but not limited to Medicare, Medicaid, Medigap, VA, DOD, TriCare or where otherwise prohibited by federal or state law are not allowable. Additionally, claims paid using any form of medical savings account (or future submission to) are not allowed; this includes, but is not limited to:, additional forms of insurance, Flexible Spending Accounts (FSA), or Health Savings Accounts (HSA).
  4. Provide a copy of the following:
    • Front and Back of Your Insurance Card
    • Your Prescription Medication Label
    • Your Prescription Medication Receipt
  5. Please be sure to certify where appropriate on the following pages.
 
 
*ViiVConnect Copay Program ID#:
*Patient First Name:  
*Patient Last Name:  
*Patient Date of Birth:

Reimbursement Payment Terms
Read the following statements and check the box to agree:
  • The information provided in this request will be accurate
  • Expenses requested for payment were not and will not be paid by any other source, including but not limited to my insurance, my Flexible Spending Account (FSA), or Health Savings Account (HSA), or any other type of medical savings account
  • I am not covered by any state or federally funded programs, including but not limited to Medicare, Medicaid, Medigap, VA, DOD, TriCare or where otherwise prohibited by federal or state law.

Note: Call 866-747-1170 if you would prefer to not submit online. Mail-in instructions will be provided.


* Indicates Required Field