➋ |ircle the medication name, the date and the amount you paid for XELJANZ XR or XELJANZ on your original pharmacy receipt. Limits, terms, and conditions apply, and are listed on this page.Ĭo-pay Rebate Form REBATE PROGRAM INSTRUCTIONS: If your pharmacy does not accept or cannot process your XELJANZ XR/XELJANZ Co-pay Savings Card, use this Rebate Form to request reimbursement of your XELJANZ XR or XELJANZ out-of-pocket co-pay costs.* ➊ |omplete the rebate form below.
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If you have questions or are in need of additional support, call 1-844-XELJANZ (1-84) or visit Please see accompanying full Prescribing Information, including BOXED WARNING and Medication Guide. Pfizer reserves the right to rescind, revoke or amend the program without notice. The Card is limited to 1 per person during this offering period and is not transferable. The Card is not valid where prohibited by law. The Card will be accepted only at participating pharmacies.
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Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. You must deduct the value of this coupon from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf. The Card may be used once per month for the life of the program. After a maximum of $12,000, you will be responsible for paying the remaining monthly out-ofpocket costs. You will receive a maximum benefit of $12,000 per calendar year, which is defined by the date of enrollment through December 31st of the enrollment year, with a $0 per month co-pay.
This Card is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other health or pharmacy benefit programs. The Card is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state prescription drug assistance programs and the Government Health Insurance Plan, available in Puerto Rico, formerly known as “La Reforma de Salud”). XELJANZ CO-PAY CARD TERMS AND CONDITIONS: By using the XELJANZ XR/XELJANZ Instant Co-pay Savings Card (the “Card”), you acknowledge that you currently meet the eligibility criteria and will comply with the following terms and conditions. Additional co-pay savings program options may be available through XELSOURCE if your pharmacy doesn’t accept or cannot process the XELJANZ XR/XELJANZ Co-pay Savings Card. If you are currently taking XELJANZ XR or XELJANZ, you can take advantage of personalized support services to help with access to your treatment. For help processing this card, call 1-86. For uninsured patients, submit claim to PDM under BIN 610020. Submit SECONDARY claim to PDM under BIN 610020. PHARMACIST’S INSTRUCTIONS FOR USE: For insured patients, process a coordination of benefits (COB/split bill) claim using patient’s prescription insurance for PRIMARY claim. If your pharmacy does not accept the XELJANZ XR/XELJANZ Co-pay Savings Card, you may still be eligible for out-of-pocket cost support through our Co-pay Rebate Program. Your Co-Pay Card can help you continue receiving XELJANZ XR or XELJANZ for as little as $0 out-of-pocket per month. ➌ Use your card every time you refill your XELJANZ XR or XELJANZ prescription. Provide this information when ordering from a specialty pharmacy or bring this printout when filling your prescription at a retail pharmacy like CVS or Walgreens. ➋ Instantly save on your XELJANZ XR or XELJANZ out-of-pocket costs with yourĬo-pay card. PATIENT’S INSTRUCTIONS FOR USE: ➊ zctivate your card now by calling 1-84. Be sure to keep this printout for all future XELJANZ XR or XELJANZ refills.
You will not receive another card in the mail.
Reduce your out-of-pocket costs to as little as $0 per month* Please note: This is your permanent card.
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