PRESCRIBED A PFIZER FACTOR PRODUCT BY YOUR HEALTH CARE PROVIDER FOR THE FIRST TIME?
Follow the steps below to find out if you are eligible to access the Pfizer Trial Prescription Program.
- Download enrollment form below
- Bring it to your next visit with your health care provider
- Work with your health care provider to complete and submit the enrollment form
Those living with hemophilia ADOWNLOAD HERE
Those living with hemophilia BDOWNLOAD HERE
OFFER TERMS: By enrolling in the 1-month trial program for Pfizer Factor Product, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:
You (the patient) are currently covered by a private (commercial) insurance plan. The patient, or health care provider on the patient’s behalf, must provide a completed enrollment form and a valid prescription to the Pfizer Factor Product Trial Prescription Program. The program is valid for one 1-month trial of up to 20,000 IU of factor. Trial cannot exceed 30 days. The patient, or the health care provider on the patient’s behalf, must not submit any claim for reimbursement for product dispensed pursuant to this program to any third-party payor, including Medicaid, Medicare, or any other federal or state health care program. The patient must not apply the value of the free product received through this program toward any government insurance benefit out-of-pocket spending calculations, such as Medicare Part D True Out-of-Pocket Costs (TrOOP). The free trial offer is not valid for prescriptions that are eligible to be reimbursed by private insurance plans or health or pharmacy benefit programs that reimburse you for the entire cost of your prescription drugs. Patients who have already begun therapy with or who have been treated with Pfizer Factor Product are not eligible to participate in the program. Only new patients may use this offer. Only 1 program enrollment per person per lifetime. By redeeming this offer, you certify that you are not currently using Pfizer Factor Product. Program not available where prohibited by law. This free trial is not health insurance. This program cannot be combined with any other savings, free trial, or similar offers for the specified prescription. The free trial offer will only be accepted by participating factor providers. Offer good only in the United States and Puerto Rico. This offer is not transferable. Pfizer reserves the right to rescind, revoke, or amend this free trial program without notice. No membership fees. For questions about the Pfizer Factor Product Trial Prescription Program, please call 1-844-989-HEMO (4366) or write to us at Pfizer Factor Product Trial Prescription Program Administrator, MedVantx, PO Box 5736, Sioux Falls, SD 57117-5736.