• One number with access to all of Pfizer Hemophilia's patient resources and support programs
• Financial support programs for eligible patients

FULL TERMS AND CONDITIONS

By using the Pfizer Factor Savings Card, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:
 

• Eligible patients with commercial prescription drug insurance coverage for Benefix or Xyntha may pay as little as $0 per prescription fill. Patient out of pocket expense will vary. The value of this offer is limited to annual benefit of $12,000. Once a patient reaches the annual maximum benefit patient is responsible for paying the remaining monthly out of pocket costs.
• Patients are not eligible for this offer if they are enrolled in a state or federally funded insurance program, including but not limited to Medicare, Medicaid, TRICARE, Veteran 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.
• This offer 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 offer 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 the Factor Savings Program to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the co-pay card, as may be required. You should not use the co-pay card if your insurer or health plan prohibits use of manufacturer co-pay cards.
• This co-pay card is not valid for Massachusetts residents whose prescriptions are covered in whole or in part by third party insurance.
• This co-pay card is not valid where prohibited by law.
• The benefit under the co-pay card program is offered to, and intended for the sole benefit of, eligible patients and may not be transferred to or utilized for the benefit of third parties, including, without limitation, third party payers, pharmacy benefit managers, or the agents of either.
• Third party payers, pharmacy benefit managers, or the agents of either, are prohibited from assisting patients with enrolling in the co-pay card program.
• Co-pay card cannot be combined with any other external savings, free trial or similar offer for the specified prescription (including any program offered by a third party payer or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations, through arrangements that may be referred to as “accumulator adjustment” or “co-pay maximizer” programs).
• Some health insurers or pharmacy benefit managers (or their agents) may have established accumulator adjustment or co-pay maximizer programs based on the availability of support under the offer [coupon/co-pay card] program and/or exclude the financial assistance provided under the offer [coupon/co-pay card] program from counting towards patient deductibles or out-of-pocket cost limitations.
• Patients subject to an accumulator adjustment or co-pay maximizer program are not eligible for this offer. Since you may be unaware whether you are subject to an accumulator adjustment or co-pay maximizer program when you enroll in this offer, Pfizer may monitor program utilization data and reserves the right to discontinue, reduce, or otherwise modify this offer at any time without notice.
• Co-pay 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.
• This co-pay card is not health insurance.
• Offer good only in the U.S. and Puerto Rico.
• Co-pay card is limited to 1 per person during this offering period and is not transferable.
• A co-pay 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 co-pay 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 co-pay card redemptions and will not identify you.
• Pfizer reserves the right to rescind, revoke or amend this offer without notice.
• Offer expires 12/31/2026.
• For questions regarding the offer, please call 1-888-733-2030, visit www.PfizerHemophiliaSupport.com or write Pfizer Hemophilia Connect, 600 Emerson Road, 3rd Floor, Suite 300, Creve Coeur, MO 63141

If you have questions, please call 1-888-733-2030 or send questions to:
IQVIA Inc. Claims Processing
430 Mountain Avenue, Suite 105
New Providence, NJ 07974

1. Discuss with your patient and determine if XYNTHA is right for him/her.
2. Review program eligibility terms with your patient. He/she must be covered by a private (commercial) insurance plan.
3. Download and complete the enrollment and authorization forms. Direct your patient to download the appropriate forms. If the patient has difficulty accessing the form he/she may also contact his/her local Pfizer Hemophilia Patient Navigator or our hotline number, 1-888-733-2030. To enroll, your eligible patient must read the terms and conditions and complete parts 1 to 4 of the form; parts 5 to 13 are to be completed by the physician.
4. Complete the prescription and submit the forms. Fax the completed form with the prescription and the patient authorization form to 1-888-868-8660. Fax must be sent from a health care provider's office. You may also mail required documents to:

Trial Prescription Program Administrator, MedVantx
PO Box 5736
Sioux Falls, SD 57117-5736

Please note that processing and delivery may take 1 to 3 weeks after the submission of the form.

For any questions about completing the Factor Product Trial Prescription Program application, please call 1-888-733-2030, Monday through Friday, 9:00 AM to 5:00 PM ET for more information​​​​​​.​​​