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 $6,000–$15,000 per calendar year, 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 12/31/2023.

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