Otsuka Canada

Pharmacy Claim Form

– Price adjustment reimbursement request

In response to the price decrease of Abilify Maintena 300mg and 400mg, Otsuka will be reviewing pharmacy reimbursement requests on a case-by-case basis. In order to consider your request, please consider the Price change detail below to fill the form.

Please select your province/territory to see the effective date of the price decrease

Province: —

Price: —

Effective Date: —

Abilify Maintena product information

UPC CODE	DIN	ITEM NUMBER	DESCRIPTION	STRENGTH	UNIT SIZE	CASE QTY
694785030019	02420864	517471	Abilify Maintena 300 mg	300 mg	1	24
694785030026	02420872	517470	Abilify Maintena 400 mg	400 mg	1	24

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Unique ID

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Submission Language

Pharmacy Information

Pharmacy Name

Pharmacy License Number

Address

Street Address City Province Postal Code

Contact Name*

First Last

Contact Email

Contact Phone Number

Product and Purchasing Information

Inventory On Hand as of

Inventory

Quantity	Product	Lot Number	Lot Number	Expiration Date	Purchasing date	Purchasing Price/Unit	Point of purchase (distributor)	Calculated refund	Actions

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Required Documentation

To avoid delays or potential refusal, please ensure all required documents are attached before submitting your claim.

Please attach the following:
Copy of invoice or proof of purchase
Photo or scan of current inventory (optional but helpful)

Submission documents*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

To report an adverse event, a product quality complaint or any feedback on Abilify Maintena, DO NOT USE THIS FORM, please contact the Medical Information and Drug Safety Department directly by phone: 1-877-341-9245, fax: 1-844-268-9110 or by email OCPI-medInfo@otsuka-ca.com

Additional Comments

Comments

Declaration

By signing below, I confirm that the information provided above is accurate to the best of my knowledge and I understand that submitting this form does not guarantee reimbursement and that my request will be evaluated by Otsuka Canada Pharmaceutical Inc. on a case-by-case basis.

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Date

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