ABSORICA® | ABSORICA Co-Pay Card Program

The ABSORICA Co-Pay Card Program offers ABSORICA patients a discount coupon card to help cover the cost of their treatment. Certain eligibility requirements and restrictions apply.

Summary of Program:

For commercially insured patients only^*
Present discount coupon card to pharmacy
Call our Help Desk at 1-855-820-9189 for more processing information
Valid for five fills and subject to applicable program maximum restrictions

* Patients are not eligible if prescriptions are paid in part or full by any state or federally funded programs including but not limited to Medicare or Medicaid, Medigap, VA, DOD, or TriCare and where prohibited by law.

To obtain your ABSORICA Co-Pay Card and begin saving, please provide the following information. If you already have your card, activate it by entering your Card ID and completing the form below.

Card ID (please leave blank if you do not yet have a card)

First Name*

Last Name*

Address – Line 1

Address – Line 2

City

State

Zip Code*

Date of Birth*

Patient’s 10-Digit Phone Number*

Email Address*

Preferred Method of Contact

Are you enrolled in any government, state or federally funded medical or prescription benefit program, including but not limited to Medicare, Medicaid, VA, DOD and Tricare?*

Do you have commercial insurance coverage?*

You understand that the personal information you provide and information pertaining to the use of your ABSORICA Co-Pay Card at the pharmacy will be shared with Sun Pharma and its third party partners. Sun Pharma and companies providing services to Sun Pharma will not sell or rent your personally identifiable information, as described in the Privacy Policy.*

You agree to be contacted at the phone number, address or email provided to receive information about products, services and promotional offers from Sun Dermatology. You understand that you have the ability to opt out of these by calling 855-820-9189 or clicking on the link contained in the email.*

*Field is required.
†Past start date or anticipated start date.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.