HOW THE PROGRAM WORKS

  1. Enroll in the Factor Savings Program

    You will then be given an 11-digit member number/patient identifier.
    Eligible Patients: Commercially insured patients whose health insurance covers factor.
    Enrollment in the Factor Savings Program ensures eligibility.
    Noneligible Patients: Patients on government assistance health care programs.

    ENROLL HERE

  2. Co-pay collection

    After you receive your factor treatment, your physician follows his or her standard procedure for co-pay collection.

  3. Explanation of Benefits (EOB)

    Your provider then submits your claim to your health insurance company, after which you and your provider receive an EOB statement.

  4. Complete and submit Co-Pay Rebate Form

    If the product is covered by your health insurance, you and/or your provider fill out a Co-Pay Rebate form using your unique 11-digit member number. The enrollment form and the EOB must then be faxed to the Factor Savings Card Program at 1-908-548-9260.*

    DOWNLOAD FORM

  5. Processing

    The Factor Savings Program coordinator reviews the EOB and co-pay rebate form and will determine approval status.

  6. Payment

    Your provider/treatment center will receive reimbursement via check. The check will be made out and sent via mail to the site address provided, unless otherwise indicated.

  7. Submitting future claims

    For each subsequent claim, an EOB may be submitted with your 11-digit member number/patient identifier to the same fax number in order to continue to receive benefits from the program.‡

*Please note: Patient or physician must provide the savings card member number on the form. Fax numbers for the site must be up to date if applying for a Factor Savings Card. Physician signature is required. Patient or physician must indicate if submitting enrollment for Factor Savings Card or reimbursement via check. All checks will go to the treatment site unless otherwise indicated.

‡Maximum benefit is $12,000/year.

CO-PAY SAVINGS CARD REBATE TERMS AND CONDITIONS By submitting this Pfizer Factor Savings Card rebate form, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

Patients must have private insurance. Offer is not valid for cash-paying patients. The value of the Factor Savings Card is limited to $12,000 per calendar year or the amount of your co-pay over 1 year, whichever less. The Factor Savings Card cannot be combined with any other savings, free trial, or similar offers for the specified prescription. Patients are not eligible to use this Card if they are enrolled in a state or federally funded insurance program, including but not limited to Medicaid, Medicare, 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”). This rebate 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 will receive $12,000 or the amount of the co-pay you paid, whichever is less. This program is limited to a maximum of $12,000 per patient per year. Patient must submit a completed rebate request form and the original, dated store-identified receipt accompanying your prescription as proof of purchase to Pfizer Hemophilia Connect at the address provided on this rebate form. Receipt will not be returned. See instructions on rebate request form. Rebate will be mailed to patients approximately 6 to 8 weeks after receipt of required documentation or earlier, as required by law. You must deduct the value received under this rebate from any reimbursement request submitted to your private insurance plan, either directly by you or on your behalf. You are responsible for reporting receipt of rebate to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription for which the patient receives a rebate, as may be required. You should not use this program if your private insurer or health plan prohibits use of manufacturer coupons, co-pay cards, debit cards or similar savings programs. This rebate is not valid where prohibited by law. The benefit under the rebate 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. This rebate 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” or “maximizer” programs). Third party payers, pharmacy benefit managers, or the agents of either, are prohibited from assisting patients with enrolling in the rebate program. This rebate is not health insurance. Offer good only in the U.S. and Puerto Rico. No other purchase is necessary. Data related to your redemption of the rebate 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 rebate redemptions and will not identify you. Pfizer reserves the right to rescind, revoke or amend the program without notice. This rebate program expires 12/31/2025.

If you have questions, please call
1-888-733-2030 or send questions to:

Pfizer Factor Savings Program
430 Mountain Avenue, Suite 105, New Providence, NJ 07974