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Copay Rebate Form REBATE PROGRAM INSTRUCTIONS:If your pharmacy does not accept or cannot process your CIBINQOTM (abrocitinib)/ LITFULOTM (ritlecitinib)/EUROPA (crisaborole) Copay Savings Card, use

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How to fill out copay rebate form

01

Obtain a copay rebate form from your healthcare provider or pharmacy.

02

Fill out your personal information, including name, address, and contact details.

03

Provide information about the prescription medication for which you are seeking a rebate.

04

Attach a copy of the receipt from your pharmacy showing the copay amount paid.

05

Submit the completed form and receipt to the designated address or online portal.

Who needs copay rebate form?

01

Individuals who have prescription medications that require a copay payment can benefit from using a copay rebate form.

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What is copay rebate form?

The copay rebate form is a document that allows individuals to claim a reimbursement for out-of-pocket expenses paid for medical services or prescriptions.

Who is required to file copay rebate form?

Individuals who have incurred copays for medical services or prescriptions and wish to seek reimbursement are required to file the copay rebate form.

How to fill out copay rebate form?

To fill out the copay rebate form, individuals must provide details of the medical service or prescription for which they paid a copay, along with proof of payment.

What is the purpose of copay rebate form?

The purpose of the copay rebate form is to allow individuals to recoup some or all of the out-of-pocket expenses they incurred for medical services or prescriptions.

What information must be reported on copay rebate form?

The copay rebate form must include details of the medical service or prescription, the amount of the copay paid, and proof of payment.

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