Pfizer encompass Co-Pay Assistance Program for INFLECTRA :

Transcription

1 Pfizer encompass Co-Pay Assistance Program for INFLECTRA : Guide to Claim Submission and Payment INFLECTRA is a trademark of Hospira UK, a Pfizer company. Pfizer encompass is a trademark of Pfizer.

2 Table of Contents Introduction... 3 Submission of Claims to the Pfizer encompass Co-Pay Assistance Program... 4 Submission of INFLECTRA Co-Pay Claims Using Claim Form: Sample Completed Form... 5 Submission of INFLECTRA Co-Pay Claims Using Your Office Billing Software... 6 Submission of INFLECTRA Co-Pay Claims Using Claim.MD... 7 Registering With EnrollHub to Receive HCP Co-Pay Remittance Through Electronic Funds Transfer (EFT) Specialty Pharmacy Submission of Co-Pay Claims Pfizer encompass Co-Pay Assistance Program for INFLECTRA Specialty Pharmacy Form This brochure describes the steps for submission of co-pay claims by healthcare providers (HCPs) to the Pfizer encompass Co-Pay Assistance Program for INFLECTRA (infliximab-dyyb) for Injection and how to register for co-pay remittance via electronic funds transfer (EFT). The process for a specialty pharmacy to submit co-pay claims is also described in this brochure. Pfizer encompass Contact Information If you have questions about the Pfizer encompass Co-Pay Assistance Program for INFLECTRA or would like to know more about patient support available through Pfizer encompass, please contact a Pfizer encompass Access Counselor or visit for more information: Monday Friday 9 am 8 pm ET Pfizer encompass P.O. Box Charlotte, NC NOTE: Co-Pay Enrollment Form and Claim Form are available on this website as downloadable, writeable PDFs Pfizer encompass Provider Portal Pfizer encompass has a secure provider portal at for HCPs and their staff. The portal allows the convenience of online, real-time access to Pfizer encompass services and resources through electronic submission of requests for a variety of Pfizer support services, including patient insurance benefit verifications (BVs) and tracking the progress of patient requests. To get started, select one of the following options: Visit and click Register Now Contact your INFLECTRA Field Reimbursement Manager for more information on how to register Call Pfizer encompass at to speak to an Access Counselor about getting started in the Provider Portal 2

3 Introduction This guide provides important information to HCPs about the options for co-pay claim submission and receiving co-pay payments available through the Pfizer encompass Co-Pay Assistance Program for INFLECTRA. The Pfizer encompass Co-Pay Assistance Program for INFLECTRA provides eligible commercially insured patients assistance up to $20,000 per calendar year. Patients now may pay $0 per INFLECTRA treatment for claims received by the program as of April 1, The co-pay program covers only drug costs, not procedures, administration fees, or office visits. Please see full Terms and Conditions below. Physicians, specialty pharmacies (SPs) or patients may submit a co-pay claim to receive payment. The INFLECTRA co-pay program can provide co-pay assistance under either a medical or pharmacy coverage benefit. For patients to be eligible for this program, they must have commercial insurance that covers INFLECTRA, and they cannot be enrolled in a state- or federally funded insurance program. INFLECTRA Co-Pay Assistance Program Overview HCP Buys and Bills SP Purchases and Bills Enrollment Patient enrolls in/is approved for co-pay program Patient assigns co-pay benefit to HCP Patient enrolls in/is approved for co-pay program Patient does not assign co-pay benefit to HCP Patient enrolls in/is approved for co-pay program HCP sends completed Pfizer encompass Co-Pay Assistance Program SP Form and INFLECTRA prescription to SP Claims Submission and Payment HCP submits co-pay claim form with EOB HCP receives co-pay payment Patient submits co-pay claim form with EOB Patient receives co-pay payment SP submits co-pay claim SP receives co-pay payment Terms and Conditions The Pfizer encompass Co-Pay Assistance Program for INFLECTRA is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state prescription drug assistance programs) and the Government Health Insurance Plan available in Puerto Rico (formerly known as La Reforma de Salud ). This program is not health insurance. No membership fees required. With this program, eligible patients may be responsible for $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. No claim for reimbursement of the out-of-pocket expense amount covered by this program shall be submitted to any third-party payer, whether public or private. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other health or pharmacy benefit programs. This offer cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription. This offer is limited to 1 per person during this offering period and is not transferable. Offer good only in the United States and Puerto Rico. Certain restrictions may apply. Offer may not be available to patients in all states. This offer is not valid where prohibited by law, taxed, or restricted. Pfizer reserves the right to rescind, revoke, or amend this offer without notice. By using this program, you understand and agree to comply with the terms and conditions as set forth above. For more information about Pfizer, visit For more information about the Pfizer encompass Co-Pay Assistance Program, call Pfizer encompass at , or write to Pfizer encompass Co-Pay Assistance Program, P.O. Box , Charlotte, NC

4 Submission of Claims to the Pfizer encompass Co-Pay Assistance Program When the HCP Purchases and Bills for the Drug (Buy-and-Bill Scenario) HCPs have 3 ways to submit claims to the co-pay assistance program for INFLECTRA: 1. Fax or mail a Pfizer encompass Co-Pay Assistance Program Claim Form 2. Utilize your practice s billing software 3. Utilize Claim.MD a. Upload claims directly b. Submit claims manually c. Submit claims via secure file transfer protocol (sftp) HCP Claims Submission: Buy-and-Bill For additional information on submitting claims via Claim.MD, refer to the Submission of INFLECTRA Co-Pay Claims Using Claim.MD instructions on pages 7-10 of this brochure. Tip: A sample completed Pfizer encompass Co-Pay Assistance Program Claim Form is found on page 5. A co-pay claim form is submitted after the patient is approved and enrolled in the INFLECTRA Co-Pay Assistance Program. The HCP must submit copies of explanations of benefits (EOBs) for INFLECTRA claims submitted to the patient s primary and secondary insurance (if applicable) with the INFLECTRA co-pay claim form. 4

5 Submission of INFLECTRA Co-Pay Claims Using Claim Form: Sample Completed Form The Pfizer encompass Co-Pay Assistance Program for INFLECTRA (infliximab-dyyb) for Injection provides eligible commercially insured patients assistance up to $20,000 per calendar year for claims received by the program as of April 1, Eligible enrolled patients now may pay $0 for each INFLECTRA treatment. The co-pay program covers only drug costs, not procedures, administration fees, or office visits. Please see full Terms and Conditions below. If you have questions about the Pfizer encompass Co-Pay Assistance Program or if there are any changes to the patient s provider, administering provider infusion provider, insurance, or contact information, please call us at Access Counselors are available Monday Friday, 9 am 8 pm ET. If there are any updates to the patient s insurance, please provide it in the noted area below. Pfizer encompass Co-Pay Assistance Program CLAIM FORM Please fax the completed form to If you have questions, please call Patients may be eligible for this offer if they: Have commercial insurance that covers INFLECTRA Are not enrolled in a state or federally funded insurance program CLAIMS PROCESS NOTE: Patients must be enrolled in the Pfizer encompass Co-Pay Assistance Program. Please submit the following: A completed claim form within 120 days of the issue date on the patient s Explanation of Benefits (EOB) A copy of the EOB or dated pharmacy receipt if the prescription was filled by a pharmacy The group and member ID information on the Pfizer encompass Co-Pay Assistance Program identification card (provided on the approval letter) Submit claims via mail or fax: Mail: Pfizer encompass Co-Pay Assistance Program P.O. Box 7017, Bedminster, NJ Fax: Pfizer encompass Co-Pay Assistance Program CLAIM FORM All fields marked with an asterisk (*) are required. ADMINISTERING PROVIDER (Enter the name of the administering provider or infusion center) Regional Medical Center PRACTICE NAME Holly *PROVIDER FIRST NAME PATIENT Jane Smith *PATIENT FIRST NAME *PATIENT LAST NAME PATIENT MIDDLE INITIAL /11/ /01/ *ZIP CODE *DATE OF BIRTH *DATE OF SERVICE *PATIENT OUT-OF-POCKET AMOUNT FOR INFLECTRA EC Male Female *PATIENT GROUP NUMBER *PATIENT MEMBER ID NUMBER *GENDER (ie, EX ) (from program ID card on the (11-digit ID from program ID card on the approval approval letter) letter) UPDATED INSURANCE DETAIL (if the insurance has changed since last submission) PRIMARY INSURANCE NAME Doe, MD PRIMARY INSURANCE GROUP # FOR MEDICAL BENEFIT *PROVIDER LAST NAME SAMPLE PRIMARY INSURANCE GROUP ID FOR MEDICAL BENEFIT Claims Submission: Co-Pay Claim Form PRIMARY INSURANCE BIN FOR PHARMACY BENEFIT PRIMARY INSURANCE PCN FOR PHARMACY BENEFIT PRIMARY INSURANCE GROUP # FOR PHARMACY BENEFIT PRIMARY INSURANCE ID FOR PHARMACY BENEFIT Terms and Conditions: The Pfizer encompass Co-Pay Assistance Program for INFLECTRA is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state prescription drug assistance programs) and the Government Health Insurance Plan available in Puerto Rico (formerly known as La Reforma de Salud ). This program is not health insurance. No membership fees required. With this program, eligible patients may be responsible for $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per calendar year for outof-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. No claim for reimbursement of the out-of-pocket expense amount covered by this program shall be submitted to any third-party payer, whether public or private. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other health or pharmacy benefit programs. This offer cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription. This offer is limited to 1 per person during this offering period and is not transferable. Offer good only in the United States and Puerto Rico. Certain restrictions may apply. Offer may not be available to patients in all states. This offer is not valid where prohibited by law, taxed, or restricted. Pfizer reserves the right to rescind, revoke, or amend this offer without notice. By using this program, you understand and agree to comply with the terms and conditions as set forth above. For more information about Pfizer, visit For more information about the Pfizer encompass Co-Pay Assistance Program, call Pfizer encompass at , or write to Pfizer encompass Co-Pay Assistance Program, P.O. Box , Charlotte, NC PEN-IFA Pfizer Inc. All rights reserved. Printed in USA/March

6 Submission of INFLECTRA Co-Pay Claims Electronically Using Your Office Billing Software 1. Within your billing software, search for PSKW0 (PSKW zero) as an available payer. If PSKW0 is an available payer, you may begin submitting electronic claims transactions (837 files) If PSKW0 is not available, please work directly with your software vendor to add PSKW0 as an available payer Claims Submission: Billing Software After confirming that PSKW0 is an available payer within your software, please add the INFLECTRA Co-Pay Program to your patient s insurance profile as a secondary payer. Make sure to include the payer ID (PSKW0), group number (EC ), and program member ID. Claims submitted without this information will be rejected automatically 2. Request that your practice management software vendor accept electronic remittance advice (ERA) (835) transactions from PSKW0. After this request is fulfilled by your vendor, you should receive an ERA approximately 5 to 7 business days after claim submission Additional information on submission of co-pay claims electronically through Claim.MD is found on pages 7-10 of this brochure. 6

7 Submission of INFLECTRA Co-Pay Claims Using Claim.MD The co-pay payer for the INFLECTRA Co-Pay Program has an established relationship with Claim.MD. HCPs can submit INFLECTRA co-pay claims through Claim.MD by completing the following steps: 1. Register and complete account setup with Claim.MD. Your IT and EDI Coordinator may be able to help. 2. Once registered, INFLECTRA co-pay claims can be submitted by one of the following methods: a. Upload claims directly b. Upload claims manually c. Submit claims via sftp Claims Submission: Claim.MD Details on each of the above methods for use of Claim.MD to submit INFLECTRA co-pay claims are found on pages 8-10 of this brochure. Some co-pay payers have established relationships with leading software vendors and clearinghouses, such as the entities listed below. If a specific entity is not listed, please contact Pfizer encompass at for assistance. Change Healthcare Claim.MD ClaimLogic/TriZetto Availity ABILITY Network Infinedi Capario eclaims NaviCure Office Ally Passport Health RealMed 7

8 **Attention EDI Coordinator** Using Claim.MD to Upload Claims Directly Please ask the person in your office who manages EDI enrollment to complete the following steps to register and get started: Navigate to the registration site at claim.md/crx/ 1. Complete the required personal information to begin the registration You will receive an activation . Click the link within the to continue the registration process 2. Complete your account setup Provide your practice name and contact details Select your billing system. If your billing system is not listed, choose Other Select Full Access in the vendor access field on the vendor settings page Review and agree to the Business Associate Agreement Provide practice details 3. Complete the claims-mapping process Select Upload Claims from the claim menu Select the claim to be uploaded and click Upload Selected File Within 3 to 5 business days, you will receive an notification that you may begin uploading claims Once complete, you will receive a confirmation from Claim.MD that will include your username and account ID. Follow these steps to begin uploading claim files within the web interface: 1. Create a claim file within your billing system Refer to your individual billing system instructions on how to do this 2. Navigate to Claim.MD website at claim.md/crx/ 3. Log in to your account 4. Upload claims Select Upload Claims from the claim menu Select the claim to be uploaded and click Upload Selected File 5. Transmit the claim Select Manage Claims from the claim menu Select Approve Transmit Once a claim is submitted, you should receive an ERA within the Claim.MD interface within approximately 5 to 7 business days. 8

9 Using Claim.MD to Upload Claims Manually Please ask the person in your office who manages EDI enrollment to complete the following steps to register and get started: Navigate to the registration site at claim.md/crx/ 1. Complete the required personal information to begin the registration You will receive an activation . Click the link within the to continue the registration process 2. Complete your account setup Provide your practice name and contact details Select your billing system. If your billing system is not listed, choose Other Select Full Access in the vendor access field on the vendor settings page Review and agree to the Business Associate Agreement Provide practice details Once complete, you will receive a confirmation from Claim.MD that will include your username and account ID. Follow these steps to begin uploading claims: Navigate to the Claim.MD website at claim.md/crx/ 1. Log in to your account 2. Enter a claim Select Manage Claims from the claim menu Select Create Blank Claim Complete claim data entry To ensure accurate transmission, make sure that PSKW0 is selected as a secondary payer Save the claim 3. Transmit the claim Select Manage Claims from the claim menu Select Approve Transmit Once a claim is submitted, you should receive an ERA within the Claim.MD interface within approximately 5 to 7 business days. 9

10 Using Claim.MD to Submit Claims via sftp Please ask the person in your office who manages EDI enrollment to complete the following steps to register and get started: Navigate to the registration site at claim.md/crx/ 1. Complete the required personal information to begin the registration You will receive an activation . Click the link within the to continue the registration process 2. Complete your account setup Provide your practice name and contact details Select your billing system. If your billing system is not listed, choose Other Select Full Access in the vendor access field on the vendor settings page Review and agree to the Business Associate Agreement Provide practice details Once complete, you will receive a confirmation from Claim.MD that will include your username and account ID. Follow these steps to begin uploading claims: Navigate to Claim.MD website at claim.md/crx/ 1. Log in to your account 2. Select Manage Users 3. Select sftp Provide your contact details Click New to submit your request Once complete, you will receive an confirming your access and sftp site information. Follow these steps to set up sftp access: 1. Connect to the sftp folder using your office s established process The sftp site address and port information will be provided in your confirmation from Claim.MD 2. Submit the claim Select the claim file Move the claim to the upload folder (/SendFiles) Please allow 5 to 7 business days for processing. You will return to the sftp site and retrieve the ERA from the download folder (/ReceiveFiles). There are many ways to access the sftp site. Please contact your facility s technical support if you are unsure about your office s process. 10

11 Registering With EnrollHub to Receive HCP Co-Pay Remittance Through EFT If a patient has checked Yes to the assignment of benefits (AOB) statement in Section 7 of the Pfizer encompass Enrollment Form to authorize co-pay payment directly to the HCP, HCPs may elect to submit the co-pay claim form and receive co-pay remittance for their patients as a paper check or through EFT. To receive payment through EFT, HCPs should register in advance of submitting the first claim to avoid payment delays. HCPs can enroll in EFT on the EnrollHub website at See the How to Register With EnrollHub to Receive EFT Payments for the Pfizer encompass Co-Pay Assistance Program instructions on pages for more information. HCP Electronic Payment Process Once registered for EFT payment, the HCP will submit the co-pay claim and the EOB from the patient s primary and/or secondary insurance (if applicable) for INFLECTRA When the co-pay claim is approved, the HCP will receive an notifying them that payment has been sent for a specific patient (see sample on page 13) Each EFT transaction in the HCP bank statement for the Pfizer encompass Co-Pay Assistance Program will be denoted as Pfizer encompass, and each patient s co-pay payment will be listed separately. Each bank may present EFT payments to its account holders differently. The HCP bank statement may include additional co-pay assistance program information, such as the patient co-pay program Member ID Number If you have any questions about your EFT transactions in your bank statement, please call Pfizer encompass at

12 How to Register With EnrollHub to Receive EFT Payments for the Pfizer encompass Co-Pay Assistance Program a New EnrollHub Users Please have the following information available: Practice name, address, phone, and fax Tax identification number Bank account information An image of a check or a bank letter Follow these steps to register and enroll in EFT: 1. Navigate to the EnrollHub website at 2. Click the Register Now button Complete the required personal information Create a username and password Set up security questions 3. Activate your account and log in You will receive an activation . Click the link within the to log in and complete the registration process 4. Create a provider record by providing practice details and banking information and uploading the check image or bank letter 5. Enroll in EFT by selecting your bank account and selecting ConnectiveRx from the payer list Accept the payment terms agreement Existing EnrollHub Users Please have the following information available: Username Login Follow these steps to register and enroll for EFT: 1. Navigate to the EnrollHub website at 2. Log in to your account 3. Enroll in EFT by selecting your bank account and selecting ConnectiveRx from the payer list Accept the payment terms agreement Complete your submission by clicking Confirm a ConnectiveRx administers the Pfizer encompass Co-Pay Assistance Program. ConnectiveRx partners with industry leading EnrollHub to support the collection of your EFT enrollment information. 12

13 EFT Payment Next Steps EnrollHub will verify your account information by submitting a payment to you in the amount of $.01 Your bank will receive the payment, verify account information, and either accept or reject the payment b You will receive an from EnrollHub notifying you of the outcome of the account verification process If rejected, please follow instructions within the to review the account information and resubmit Once your account has been approved, EnrollHub will share your enrollment with the Pfizer encompass Co-Pay Assistance Program for INFLECTRA, so no separate registration with Pfizer encompass is required. You are able to receive EFT payments for co-pay claims submitted through the Pfizer encompass Co-Pay Assistance Program for INFLECTRA within 2 to 3 weeks of enrollment. In the interim, all eligible claims will be paid by check b It may take up to 10 business days for your bank to complete this transaction. If you need more information or account support, you may access the EnrollHub Getting Started document at Pfizer encompass Co-Pay HCP EFT Notification of Funds Transfer To: <Billing Address> From: donotreply-pfizerencompass@pskw.net Pfizer encompass Co-Pay Assistance Program Subject: Pfizer encompass Co-Pay Assistance Program Electronic Funds Transfer Dear <Billing Contact Name>, Thank you for your participation in the Pfizer encompass Co-Pay Assistance Program for INFLECTRA (infliximab-dyyb) for Injection. This notification is to inform you that funds have been transferred to your account in the amount of <$$$.$$> on behalf of <Patient First name> <Patient Last name>, <Patient DOB>, covering the out-of-pocket costs for the treatment administered on <Date of Service>. This amount reflects the patient s out-of-pocket costs incurred and covered by the program. Please see full Terms and Conditions below. Please do not reply to this . This address does not accept incoming messages. If you have questions about the Pfizer encompass Co-Pay Assistance Program, or if there are any changes to the provider, administering provider, insurance coverage, or contact information, please call us at We are available Monday Friday, 9 AM 8 PM ET. Sincerely, Pfizer encompass Co-Pay Assistance Program for INFLECTRA 13

14 Processing Pfizer encompass Co-Pay Assistance Program Claims When an SP Dispenses INFLECTRA and Bills the Patient s Insurance Plan In certain cases, the HCP may send the prescription to an SP (eg, when INFLECTRA is covered under the patient s prescription benefits or when a patient s commercial insurance requires INFLECTRA to be obtained through a payeraffiliated SP). The HCP or patient provides patient co-pay information to the specialty pharmacy to process co-pay claims. The HCP completes and sends, with the prescription, the Pfizer encompass Co-Pay Assistance Program for INFLECTRA Specialty Pharmacy Form (see blank form for HCP use on next page of this resource) Specialty Pharmacy Claims Submission OR Your patient may also provide the co-pay claims-processing information on their Pfizer encompass Co-Pay Program ID Card directly to the pharmacist The pharmacy processes the co-pay claim and collects any additional balance due from the patient When an SP purchases and bills for INFLECTRA, the HCP is not responsible for billing the patient s primary insurance plan or the co-pay assistance program for INFLECTRA 14

15 Pfizer encompass Co-Pay Assistance Program for INFLECTRA (infliximab-dyyb) for Injection Specialty Pharmacy Form PLEASE NOTE: This fax form can be used by a patient's HCP to provide important information to a specialty pharmacy for a patient who has been approved and enrolled in the Pfizer encompass Co-Pay Assistance Program for INFLECTRA when a patient's INFLECTRA co-pay claim needs to be processed by the specialty pharmacy. When sending/faxing this form to a specialty pharmacy, please send/attach the prescription for INFLECTRA. TO: FAX #: (Pharmacy Name) (Pharmacy Fax) FROM: (Practice Name) DATE: TOTAL PAGES: PATIENT NAME: DATE OF BIRTH: The patient noted above has been approved to participate in the Pfizer encompass Co-Pay Assistance Program for INFLECTRA. The Pfizer encompass Co-Pay Assistance Program for INFLECTRA provides eligible commercially insured patients assistance up to $20,000 per calendar year. Patients now may pay $0 per INFLECTRA treatment for claims received by the program as of April 1, The co-pay program covers only drug costs, not procedures, administration fees or office visits. Please see full Terms and Conditions below. Specialty pharmacies should utilize the following information from the patient's Pfizer encompass Co-Pay Assistance Program identification card when submitting claims to the INFLECTRA co-pay assistance program: BIN #: PCN #: CN ID #: GROUP #: EC Patient Member Number (Use 11-digit Patient Member ID Number from the Pfizer encompass Co-Pay Assistance Program identification card sent with the patient's approval letter) Pharmacist instructions for a patient with an Authorized Third-Party Payer: Submit the claim to the primary third-party payer first, then submit the balance due for the co-pay or coinsurance, and secondary claim (if applicable) to Therapy First Plus as a secondary payer coordination of benefits (COB) with patient responsibility amount and a valid Other Coverage Code (eg, 8). The patient now may pay $0 per INFLECTRA treatment. The offer pays up to $20,000 per year. You will receive reimbursement from Therapy First Plus. For any questions regarding Therapy First Plus online processing, please call the Help Desk at If you have any questions about processing a patient's INFLECTRA co-pay claim through a pharmacy benefit or the Pfizer encompass Co-Pay Assistance Program, please call and speak to an Access Counselor. Representatives are available Monday Friday, 9 AM 8 PM ET. Terms and Conditions: The Pfizer encompass Co-Pay Assistance Program for INFLECTRA is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state prescription drug assistance programs) and the Government Health Insurance Plan available in Puerto Rico (formerly known as La Reforma de Salud ). This program is not health insurance. No membership fees required. With this program, eligible patients may be responsible for $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. No claim for reimbursement of the out-of-pocket expense amount covered by this program shall be submitted to any third-party payer, whether public or private. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other health or pharmacy benefit programs. This offer cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription. This offer is limited to 1 per person during this offering period and is not transferable. Offer good only in the United States and Puerto Rico. Certain restrictions may apply. Offer may not be available to patients in all states. This offer is not valid where prohibited by law, taxed, or restricted. Pfizer reserves the right to rescind, revoke, or amend this offer without notice. By using this program, you understand and agree to comply with the terms and conditions as set forth above. For more information about Pfizer, visit For more information about the Pfizer encompass Co-Pay Assistance Program, call Pfizer encompass at , or write to Pfizer encompass Co-Pay Assistance Program, P.O. Box , Charlotte, NC PP-IFA-USA Pfizer Inc. All rights reserved. Printed in USA/March

16 PP-IFA-USA Pfizer Inc. All rights reserved. March 2018