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Content for financial assistance

If you need assistance with co-pays or paying for your medicine, we are here to find a program that may be able to help—regardless of your insurance coverage.
SELECT AN INSURANCE STATUS

COMMERCIALLY INSURED Resources for eligible commercial, private, employer, and state health insurance marketplace patients

IV CO-PAY ASSISTANCE

If you have commercial insurance, you may be eligible for the Pfizer Oncology Together Co-Pay Program for IV ("IV Co-Pay Program"). Limits, terms, and conditions apply. See below for full Terms and Conditions.

Eligible Commercially Insured Patients* Co-pay may be as little as $0. Once the annual program limit is reached, the patient is responsible for the full co-pay.

$25,000 per Calendar Year Program covers up to $25,000 per calendar year

No Income Requirements There are no income requirements to qualify

To apply, download the Pfizer Oncology Together enrollment form and fill out the required fields and IV Co-Pay Program assistance section. This form requires some information from your healthcare provider, so it’s best to fill it out together.

ENROLLMENT FORM

*For patients to be eligible for the IV Co-Pay Program, they must have commercial insurance that covers BESPONSA, and they cannot be enrolled in a state or federally funded insurance program. Whether a co-pay expense is eligible for the IV Co-Pay Program benefit will be determined at the time the benefit is paid. Co-pay expenses must be in connection with a separately paid claim for BESPONSA administered in the outpatient setting.

The IV Co-Pay Program will pay the co-pay and any deductible obligations for BESPONSA up to the annual assistance limit of $25,000 per calendar year per patient.

IV Co-Pay Program provides assistance for eligible, commercially insured patients for co-pays, co-insurance, or deductibles incurred for BESPONSA, up to $25,000 per calendar year. It does not cover or provide support for supplies, services, procedures, or any other physician-related services associated with BESPONSA treatment.

TERMS & CONDITIONS (FOR PATIENTS)

By enrolling in the Pfizer Oncology Together Co-Pay Program for IV (“IV Co-Pay Program”), you acknowledge that you currently meet the eligibility criteria and will comply with the Terms and Conditions described below:

  1. The IV Co-Pay Program is offered to eligible BESPONSA™ (inotuzumab ozogamicin) (referred to as "Product") patients who are insured through a private/commercial health plan, and are enrolled in the IV Co-Pay Program.
  2. The IV Co-Pay Program does not cover or provide support for supplies, services, procedures, or any other physician-related services associated with Product treatment.
  3. The offer is not valid for medicines 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”).
  4. If your insurance status changes, you must notify us immediately.
  5. The offer is not valid for medicines that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs that reimburse you for the entire cost of your prescription drugs.
  6. You are entitled to maximum assistance of $25,000 per calendar year per patient.
  7. The IV Co-Pay Program will pay your co-pay and any deductible obligations for Product up to the annual assistance limit of $25,000 per calendar year per patient. You remain responsible for paying all co-pays and any balance not covered by the Program.
  8. Whether a co-pay expense is eligible for the IV Co-Pay Program benefit will be determined at the time the benefit is paid. Co-pay expenses must be in connection with a separately paid claim for Product administered in the outpatient setting.
  9. You must deduct the value received under the IV Co-Pay Program from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf.
  10. Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified medicine.
  11. Offer is limited to 1 per person during this offering period and is not transferable.
  12. The IV Co-Pay Program offer is good only in the United States and Puerto Rico.
  13. Pfizer reserves the right to rescind, revoke, or amend this offer without notice.
  14. No membership fees. This offer is not health insurance.
  15. Claims must be submitted to the IV Co-Pay Program within 120 days of the date of the Explanation of Benefits (EOB) from your primary insurance company.
  16. Offer expires 12/31/2019.
  17. The IV Co-Pay Program is not valid where prohibited by law.

For more information about the Pfizer Oncology Together Co-Pay Program for IV, call 1-877-744-5675 or write Pfizer Oncology Together Co-Pay Program for IV, P.O. Box 220366, Charlotte, NC 28222-0366.

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MEDICARE/GOVERNMENT INSURED Help identifying resources for patients with Medicare, Medicaid, and other government insurance plans

Support from independent charitable foundations

We’ll help you search for financial support that may be available from independent charitable foundations. These foundations exist independently of Pfizer and have their own eligibility criteria and application processes. Availability of support from the foundations is determined solely by the foundations.

Free MEDICINE

If independent charitable foundation support is not available, we will provide eligible patients with BESPONSA for free through the Pfizer Patient Assistance Program.§

§The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation™. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc. with distinct legal restrictions.

To get started:
For live support, call 1-877-744-5675
(Monday–Friday 8 am–8 pm ET)

 

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UNINSURED Help identifying resources for patients who do not have any form of healthcare coverage

help finding COVERAGE

We can check to see if you’re eligible for a government program that helps pay for prescription medicines through Medicaid or Medicare Part D. If you are eligible, we can guide you on how to apply, and we’ll provide assistance throughout the process

Free MEDICINE or Savings

If you do not have insurance or prescription coverage and you are unable to afford your medication, we may be able to help. Pfizer Oncology Together can provide you with BESPONSA for free or at a savings, if you are eligible, through the Pfizer Patient Assistance Program.

The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation™. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc. with distinct legal restrictions.

To get started:
For live support, call 1-877-744-5675
(Monday–Friday 8 am–8 pm ET)

 

REMEMBER, COMPLETE ALL ENROLLMENT FORMS WITH YOUR HEALTHCARE TEAM

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