Submit Your Co-pay Claim

Please select a file saved on your device in one of the formats listed below to upload and submit a co-pay claim for SUNLENCA^® (lenacapavir).

Patient Co-pay Card ID Number:

*Required field

A card ID must be entered to proceed A card ID must be a 9-digit or an 11-digit number Your 9-digit card number is no longer valid. Please complete the enrollment process here to get a new 11-digit card number. The information you entered is not valid. Please try again. If you still have trouble, please call 1-800-226-20561-800-226-2056 for assistance

A medical ID must be a 9-digit or an 11-digit number

Document Upload

Select a document to upload The file extension is not allowed. The file you tried to upload exceeds the maximum size allowed. Please upload a required document

By checking this box, I certify that I have the patient's permission to upload their EOB documentation to the co-pay coupon program vendor.

*Required field

In order to submit your claim, you must certify permission on behalf of the patient. If you would like to discuss further, please call 1-800-226-20561-800-226-2056 for assistance

In order to submit your claim, you must certify permission on behalf of the patient. If you would like to discuss further, please call 1-800-226-2056 1-800-226-2056 for assistance