Xeljanz rebate form 2026

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The document provides instructions for submitting a co-pay rebate form for XELJANZ (tofacitinib citrate) to request reimbursement of out-of-pocket costs when the pharmacy cannot process the Co-pay Savings Card. It outlines the steps to complete the form, eligibility criteria, and important safety information regarding XELJANZ, including potential side effects and conditions under which it should not be used.

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Click ‘Get Form’ to open the XELJANZ Co-pay Rebate Form in the editor.
Begin by filling in your personal information, including your name, address, city, state, zip code, phone number, and email. Ensure all details are accurate for smooth processing.
Locate the section for your Member ID Number from your XELJANZ Co-pay Savings Card and enter it carefully.
Circle the medication name 'XELJANZ', the date of purchase, and the amount paid on your original pharmacy receipt. Remember that a cash register receipt is not valid.
Scan or take a clear picture of your pharmacy receipt. This will be needed to complete your submission.
Email the completed rebate form along with the scanned pharmacy receipt to xeljanzsupport@trialcard.com.

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