Directions: For assistance, please complete this form and fax it to 1.855.854.3931. You can also call 1.844.472.2628, Monday-Friday 8 am–6 pm ET, to speak with a Vivimusta CONNECTSM Case Manager.

Click the Link Below to Start Your Submission Process

aSee Terms and Conditions Below

Terms and Conditions

By using the Vivimusta CONNECTSM 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 registered trademark of Slayback Pharma LLC, a subsidiary of Azurity Pharmaceuticals, Inc. © 2024 Azurity Pharmaceuticals, Inc. All Rights Reserved. All trademarks referred to are the property of their respective owners.