Downloadable Forms
Check Request Form
Complete this form when you are seeking reimbursement after paying the provider for your treatment. The instructions for using the program with these providers are included on the form.
IMPORTANT Program Update – Oncology Co-pay Assistance Program patients with Mastercard as a payment method may have a Mastercard number that is expiring on March 31st, 2023. These Mastercard numbers will be replaced so your provider can continue to process payments. Once a new Mastercard number is issued, the co-pay member ID is updated to align to the new Mastercard number. If you have questions, please contact the co-pay program by calling (855) MY-COPAY (855-692-6729).
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