All applicable information is required to receive a Rebate Check. Not all patients are eligible for a Rebate. This Rebate Form registration will be processed by McKesson on behalf of ViiVConnect.
Instructions for Completing the Rebate Form:
  1. PLEASE REVIEW FULL TERMS AND CONDITIONS OF YOUR VIIVCONNECT SAVINGS CARD TO CONFIRM ELIGIBILITY. Patients must be eligible to redeem the ViiVConnect Savings Card, consistent with the ViiVConnect Savings Card Terms and Conditions, to receive a Rebate Check. If you have questions about the Rebate for the product for which you are seeking a Rebate Check, 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 Savings Card, complete this Rebate 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 to request a Rebate.
  3. Provide a copy of the following:
    • Front and Back of Your Insurance Card
    • Your Prescription Medication Label
    • Your Prescription Medication Receipt
  4. Please be sure to certify where appropriate on the following pages.
 
 
*ViiVConnect Savings Card ID#:
*Patient First Name:  
*Patient Last Name:  
*Patient Date of Birth:
     

* Indicates Required Field