enroll in IMBRUVICA® patient support
Welcome to IMBRUVICA® By Your Side, a comprehensive, personalized support experience designed to help IMBRUVICA® patients start and stay on track with the treatment plan you prescribed.
IMBRUVICA® By Your Side provides:
Comprehensive Resources
Dedicated Ambassadors
Financial Guidance
Complete this form with the permission of your patient to enroll them in IMBRUVICA® By Your Side, so they can get the support they need throughout their treatment journey.

Prescriber Information
Patient Details
Insurance Information
Enrollment Complete

Registration complete!
Thank you for enrolling your patient in IMBRUVICA® By Your Side! Make sure to DOWNLOAD and PRINT or EMAIL the IMBRUVICA® By Your Side patient information to give to your patient before leaving your office.
To Request a Benefit Verification: Call: 1-888-YourSide (1-888-968-7743). Choose option 2 for Healthcare Professional. Then select option 1 to speak to an Access Specialist.

What to expect next:
Remind your patient to expect a call from an Ambassador within one business day (call may come from any area code, including a toll free number).
Ambassadors provide important educational resources, answer questions and help navigate the prescription process and identify ways patients may be able to save on IMBRUVICA®.
IMBRUVICA® Copay Card
Your patient has qualified for the copay card.

*Eligible patients may pay as little as $0 per prescription of IMBRUVICA®. Rules and maximum limits apply. Patients currently using the IMBRUVICA® Copay Card are not eligible for retroactive billing or reimbursement of previous copays. The IMBRUVICA® Copay Card is available to patients with commercial prescription coverage for IMBRUVICA® who meet eligibility criteria. The IMBRUVICA® Copay Card cannot be used by patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs, including Medicare Part D, Medicare Advantage Plan, Medicaid, Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient’s health insurance provider. The IMBRUVICA® Copay program may be updated or discontinued at any time without notice.

* Eligible patients may pay as little as $0 per prescription of IMBRUVICA®. Rules and maximum limits apply. Patients currently using the IMBRUVICA® Copay Card are not eligible for retroactive billing or reimbursement of previous copays. The IMBRUVICA® Copay Card is available to patients with commercial prescription coverage for IMBRUVICA® who meet eligibility criteria. The IMBRUVICA® Copay Card cannot be used by patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs, including Medicare Part D, Medicare Advantage Plan, Medicaid, Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient's health insurance provider. The IMBRUVICA® Copay program may be updated or discontinued at any time without notice.
By using this copay card, the patient understands and agrees to comply with these eligibility requirements and terms of use:
Eligibility
- Covered by commercial or private insurance
- Reside in the United States (including Puerto Rico, US Virgin Islands, Guam)
- The IMBRUVICA® Copay Card cannot be used by patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs, including Medicare Part D, Medicare Advantage Plan, Medicaid, Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient's health insurance provider
Terms and Conditions of the IMBRUVICA® Copay Card
- Patients currently using the IMBRUVICA® Copay Card are not eligible for retroactive billing or reimbursement of previous copays
- The IMBRUVICA® Copay program may be updated or discontinued at any time without notice
- This offer is good for eligible patients on IMBRUVICA® who are 18 years of age or older, are residents of the United States, Puerto Rico, US Virgin Islands or Guam, and have a valid prescription for IMBRUVICA®
- This program is not available to individuals enrolled in federal or state subsidized healthcare programs that cover prescription drugs, including Medicare, such as Medicare Part D prescription drug benefit, Medicare Advantage, Medicaid, TRICARE, or any other federal or state healthcare plan, including pharmaceutical assistance programs. Participants certify that they will not seek reimbursement or compensation from any of these programs, including a flexible spending account, a Health Savings Account (HSA), or a Health Reimbursement Account (HRA)
- Individuals who become enrolled in a federal or state subsidized healthcare program that covers prescription drugs at any point after enrolling in the IMBRUVICA® Copay Card program must immediately stop using their IMBRUVICA® Copay Card and call 855-332-6210 to inform RxCrossroads of their change in status. Individuals are no longer eligible for the IMBRUVICA® Copay Card program effective as of the date of their enrollment in the federal or state subsidized healthcare program
- This offer may not be combined with any other coupon, discount, prescription savings program card, free triaI or other offer
- Patients are not required to re-enroll in the program. After the initial enrollment, patients will be automatically re-enrolled for each subsequent year in the program, provided that they continue to meet eligibility criteria for the program
- Before you activate your membership in this program, it is important that you understand that you will be asked to provide personal information that may include identifiers such as your name, address, phone number, and email address, and information related to your insurance, health, and treatment. This information will be used by Pharmacyclics LLC, the manufacturer of IMBRUVICA®, and companies that work with Pharmacyclics LLC, including vendors and affiliates, to provide benefits to you related to the activation and use of your IMBRUVICA® Copay Card, and for internal business purposes including research and analytics. The information you provide will be shared with our vendors, collaborators, and affiliates and as required by law. For more information about the categories of personal information collected by Pharmacyclics and the purposes for which we use personal information, please visit www.pharmacyclics.com and click on the privacy policy link
- The IMBRUVICA® Copay Card will be accepted only at participating pharmacies
- The selling, purchasing, trading, or counterfeiting of this program information is prohibited
- Pharmacyclics LLC reserves the right to rescind, revoke, or amend this offer without notice at any time. Void where prohibited, taxed, or otherwise restricted by law