Directions: Select the option below that best matches your request. You may complete the form online and click Submit, or print the form and fax it to 1.855.854.3931.

Questions or need help? Call 1.844.472.2628, Monday–Friday 8:00 AM–6:00 PM ET, to speak with a Vivimusta CONNECT® Case Manager.

Vivimusta CONNECT® at a glance

Click the corresponding link below to fill out and submit your request:

Support Program

Speak with a Vivimusta CONNECT® Case Manager for support with:

  • Benefits Investigation
  • Prior Authorization
  • Denial management
  • Claims and appeals
Open Healthcare Provider Enrollment Form

Co-paya Savings Program

Eligible, commercially insured patients may:

  • Receive assistance with out-of-pocket costs for Vivimusta®
  • Pay as little as $10 with an annual maximum
Open Patient Co-Pay Savings Request Form

aSee Terms and Conditions Below

Terms and Conditions

By using the Vivimusta CONNECT® Co-pay Program you certify that you meet the eligibility criteria and will comply with the Terms and Conditions described below.

  • Co-pay assistance is not valid for prescriptions that are eligible for reimbursement, in whole or in part by Medicaid, Medicare, or other federal or state healthcare programs (including any state prescription drug assistance programs and the Government Health Insurance Plan available in Puerto Rico [formerly known as “La Reforma De Salud”]).
  • Co-pay assistance is not valid for prescriptions that are eligible for reimbursement by private insurance plans or other health or pharmacy benefit programs that reimburse you for the entire cost of your prescription drugs.
  • The patient must be ≥ 18 years of age to be eligible for this program
  • Each patient is limited to one active co-pay assistance offer at a time during this offer period and the co-pay assistance offer is not transferable.
  • Co-pay assistance cannot be combined with any other rebate, coupon, free trial, or similar offer for the specified prescription.
  • Co-pay assistance is not health insurance.
  • This offer is good only in the United States and Puerto Rico as allowed by law.
  • Azurity reserves the right to rescind, revoke, or amend co-pay assistance without notice.
  • Offer valid until the end of the current calendar year.

Vivimusta® is a trademark of Azurity Pharmaceuticals, Inc.

© 2025 Azurity Pharmaceuticals, Inc. All Rights Reserved. All trademarks referred to are the property of their respective owners.

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