Dupixent reimbursement form 2026

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The document outlines the reimbursement process for eligible patients who have paid their copay for DUPIXENT® within the last 90 days under the DUPIXENT MyWay® Copay Card Program. It details the necessary patient information, required documentation for submission, and emphasizes that submission does not guarantee payment. The form must be completed accurately and submitted via mail or fax to initiate the reimbursement request.

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Click ‘Get Form’ to open the dupixent reimbursement form in the editor.
Begin by filling out the 'Patient Information' section. Enter your first name, middle initial, last name, address, city, state, zip code, phone number, email address, date of birth, and select your gender.
In the 'Reimbursement Process' section, ensure all fields are completed. Attach a copy of your DUPIXENT prescription label and any required documentation as specified.
Fill in your Member ID and Group number in the designated boxes. If you have a copay card, include a copy of its front.
Sign and date the certification statement at the bottom of the form to confirm that all information is accurate and that expenses were incurred.
Submit your completed form along with attachments via mail or fax to the provided addresses.

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Versions	Form popularity	Fillable & printable
2019	4.3 Satisfied (47 Votes)
2018	4.7 Satisfied (41 Votes)

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