XELSOURCE & XELJANZ Access Terms & Conditions

PFIZER PATIENT ASSISTANCE PROGRAM ELIGIBILITY CRITERIA

• The Pfizer Patient Assistance Program is not health insurance and is available for eligible uninsured/underinsured patients only.
• Offer is only available to patients who meet financial and other criteria.
• This offer does not require, nor will it be made contingent on, purchase requirements of any kind.
• No claim for reimbursement or credit for any costs associated with the medicine(s) may be submitted to any prescription insurance provider or payer, including Medicare Part D plans.
• Pfizer reserves the right to amend, rescind, or discontinue this program at any time without notification.
• Offer good only in the U.S. and Puerto Rico.
• Patient must be a resident of the U.S. or Puerto Rico.
• Prescription must be provided by a healthcare provider licensed in the U.S. or Puerto Rico.
• Patient must be treated in the outpatient setting of care.
• Additional eligibility criteria may apply. Contact XELSOURCE for details.

INTERIM CARE Rx PROGRAM TERMS & CONDITIONS

• Interim Care Rx is not health insurance and is available for eligible, commercially insured patients only.
• Offer is only available to patients who have been diagnosed with an FDA-approved indication for XELJANZ.
• No claim for reimbursement for product dispensed pursuant to this offer may be submitted to any third-party payer.
• Not available to patients covered under government plans such as Medicaid, Medicare or other federal or state healthcare programs, including any state prescription drug assistance programs and the Government Health Insurance Plan or for residents of Massachusetts, Michigan, Minnesota, or Rhode Island.
• Available in 30-day supply. Refills are subject to limitations.
• Interim Care Rx offer does not require, nor will be made contingent on, purchase requirements of any kind.
• Pfizer reserves the right to amend, rescind, or discontinue this program at any time without notification.
• Interim Care Rx can only be dispensed by the exclusive pharmacy and only after benefits investigation has been completed and a delay occurs in the prior authorization or appeals process.
• Offer good only in the U.S. and Puerto Rico.
• Prescription must be provided by a healthcare provider licensed in the U.S. or Puerto Rico.
• Continued eligibility for the program requires the submission of two appeals within 180 days of enrollment. After 12 months of program enrollment an updated prescription and benefits investigation is required to confirm continued eligibility.
• The Interim Care Rx Program is applicable to all XELJANZ formulations.
• Additional eligibility criteria may apply. Contact XELSOURCE for details.

VOUCHER TERMS AND CONDITIONS

By redeeming this voucher, you acknowledge that you currently meet the eligibility criteria and will comply with the terms & conditions described below:

• You will receive a one-time, 30-day supply of XELJANZ.
• Only new patients may use this voucher. By redeeming this voucher, you certify that you are not currently using XELJANZ.
• An original voucher and a valid prescription must be presented to the pharmacy.
• The voucher will be accepted only at participating pharmacies.*
• You must not submit any claim for reimbursement for product dispensed pursuant to this voucher to any third-party payor, including Medicare, Medicaid, or any other federal or state health care program. You cannot apply the value of the free product received through this voucher toward any government insurance benefit out-of-pocket spending calculations, such as Medicare Part D True Out-of-Pocket Costs (TrOOP).
• This voucher is not valid where prohibited by law.
• This voucher cannot be combined with any other savings, free trial or similar offer for the specified prescription. This voucher should not be combined with samples for the specified prescription.
• This free trial voucher is not health insurance.
• This free trial voucher is not intended to address delays or gaps in health insurance coverage for the specified prescription.
• Offer good only in the U.S. and Puerto Rico.
• No purchase is necessary.
• Patients have no obligation to continue to use XELJANZ.
• Pfizer reserves the right to rescind, revoke, or amend this offer without notice.
• The voucher is applicable to all XELJANZ formulations.
• This voucher expires 12/31/2024.

^*MA residents may select their pharmacy. Otherwise, this free trial will be supplied through XELSOURCE.

CO-PAY CARD TERMS AND CONDITIONS

By using the XELJANZ Co-Pay Savings Card (the “Card”), you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

• Patients are not eligible to use the Card if they are enrolled in a state- or federally funded insurance program, including but not limited to Medicare, Medicaid, TRICARE, Veterans Affairs health care, a state prescription drug assistance program, or the Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”).
• Patient must have private insurance. Offer is not valid for cash-paying patients.
• You will receive a maximum benefit of $4,000-$15,000 per calendar year depending on insurance, which is defined by the date of enrollment through December 31st of the enrollment year. After a maximum is reached, you will be responsible for paying the remaining monthly out-of-pocket costs.
• This Card is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plan or other private health or pharmacy benefit programs.
• You must deduct the value of this Card from any reimbursement request submitted to your private insurance plan, either directly by you or on your behalf.
• You are responsible for reporting use of the Card to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Card, as may be required. You should not use the Card if your insurer or health plan prohibits use of manufacturer Cards.
• The Card is not valid where prohibited by law.
• The Card cannot be combined with any other savings, free trial, or similar offer for the specified prescription.
• The Card will be accepted only at participating pharmacies.
• If your pharmacy does not participate, you may be able to submit a request for a rebate in connection with this offer. The rebate form can be found at xeljanzrebate.com.
• The Card is not health insurance.
• Offer good only in the U.S. and Puerto Rico.
• The Card is limited to 1 per person during this offering period and is not transferable.
• The Card may not be redeemed more than once per 30 days per patient.
• No other purchase is necessary.
• Data related to your redemption of the Card may be collected, analyzed, and shared with Pfizer, for market research and other purposes related to assessing Pfizer’s programs. Data shared with Pfizer will be aggregated and de-identified; it will be combined with data related to other Card redemptions and will not identify you.
• Pfizer reserves the right to rescind, revoke, or amend the program without notice.
• The Card is applicable to all XELJANZ formulations.
• Card and Program expires 12/31/2024.

If you have questions or are in need of additional support, call 1-844-935-5269 or visit www.XELJANZ.com.