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Downloadable Form and Reimbursement Details

CMS-1500 Form

The CMS-1500 form, which can be downloaded here, is required for reimbursement.

Please send all required documentation to the following address and/or fax number below.

ConnectiveRx
Attn: Co-pay Savings Program for Kyleena
PO Box 2236
Morristown, NJ 07962
Fax: 1-833-244-2720

Eligible patients may pay as little as $20 and save up to $950. Patients who are enrolled in any type of government insurance or reimbursement programs are not eligible. As a condition precedent of the co-payment support provided under this program, e.g., co-pay refunds, participating patients and pharmacies are obligated to inform insurance companies and third-party payers of any benefits they receive and the value of this program, and may not participate if this program is prohibited by or conflicts with their private insurance policy, as required by contract or otherwise. Void where prohibited by law, taxed, or restricted. Patients enrolled in the Bayer US Patient Assistance Foundation are not eligible. Bayer may determine eligibility, monitor participation, equitably distribute product and modify or discontinue any aspect of the Co-pay Savings Program for Kyleena at any time, including but not limited to this commercial co-pay assistance program.