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Xiidra reimbursement form

Xiidra reimbursement form 2025

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The document is a reimbursement form for eligible patients using the Xiidra iinsider card, detailing the steps to obtain a rebate check if they are unable to use the card at the pharmacy. It outlines required personal information, necessary documentation such as proof of purchase and insurance details, and instructions for mailing the form. The document also highlights potential savings on prescriptions and provides contact information for assistance.

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Click ‘Get Form’ to open the xiidra reimbursement form in the editor.
Begin by filling in your personal information in the required fields. Enter your name, address, city, state, zip code, phone number, email address, date of birth, gender, Savings Card ID #, and Savings Card GRP #. Ensure all details are accurate for a smooth processing experience.
Next, include additional required information. Attach proof of purchase which should be an original pharmacy receipt containing the pharmacy name, product name, prescription number (Rx #), date filled, quantity, and price. If applicable, provide a photocopy of your primary insurance card or list your primary insurance carrier along with BIN and PCN information.
Finally, mail all completed documents to the specified address: XIIDRA CLAIMS PROCESSING DEPT., PO BOX 7017, BEDMINSTER, NJ 07921. Remember to allow 6-8 weeks for reimbursement processing.

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