Rebate Form Information

  • Only a patient is eligible for the Rebate program
  • If a patient pays out of pocket for an eligible, prescribed ViiV Healthcare medication(s) and does not utilize the ViiVConnect Savings Card, the patient can use the Rebate Form to obtain savings
  • A patient is not eligible to utilize this program if they have capped out (fully utilized the maximum benefit amount) of their ViiVConnect Savings Card eligibility

Have questions? Call McKesson Corporation (McKesson), ViiVConnect Savings Card’s administrator, at 1-866-747-1170 to speak live to an agent.

Rebate Form Instructions

We offer TWO WAYS for you to submit your Rebate Form, so you may be reimbursed for your out-of-pocket spend if your retail or mail-order pharmacy does not accept the ViiVConnect Savings Card. You may submit either online or by postal mail.

Submit Online Submit Rebate Form Online

Submit by Postal Mail

You can download, complete, and print out the form for submission via the Postal Service.

How to Complete the Rebate Form

  1. Click the button below to download the Rebate Form
    Download Rebate Form
  2. Fill out the Rebate Form
    • A. You can edit the form on your computer
    • B. You can print the form and fill it out by hand
  3. Print the Rebate Form
  4. Mail the form via the Postal Service with the following documents:
    • A. Copy of your ViiV Healthcare prescription medication receipt
    • B. Copy of the front and back of your insurance card
    • C. Copy or picture of the prescription medication label
    Including: Date of fill, name of medication, quantity, dosage strength, instructions on how to take medication, NDC, pharmacy name and location

Mailing address:

DMR
PO Box 2914
Phoenix, AZ 85062-2914

When and How Will I Get My Rebate?

Once you submit the Rebate Form, medication receipt, medication label, and insurance card (via online submission or postal mail submission), you will receive a Rebate Check in the postal mail. McKesson will mail a check to the patient within 2-4 weeks.

Your first Rebate Check will include a letter explaining that after the first check is received in the mail, you have the option of: 1) continuing to utilize postal mail for future Rebates OR 2) choosing to register for Electronic Funds Transfer (Rebate funds directly deposited into your bank account) for future Rebates. If you choose Electronic Funds Transfer, McKesson will transfer the Rebate amount to your bank account within 2-4 weeks.

Have Questions?

Call McKesson at 1-866-747-1170 to speak live to an agent.

Sample Rebate Check and Letter