XALKORI <strong>Financial Assistance</strong>
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Resources for eligible commercial, private, employer, and state health insurance marketplace coverage
Eligible, commercially insured patients may pay as little as $0 per month for XALKORI. Limits, terms, and conditions apply.*
Enrollment is simple, with no income requirements, forms, or faxing.
Help identifying resources for patients with Medicare/Medicare Part D, Medicaid, and other government insurance plans
- Assistance with searching for financial support that may be available from independent charitable foundations. These foundations exist independently of Pfizer and have their own eligibility criteria and application processes. Availability of support from the foundations is determined solely by the foundations
- Financial assistance through Extra Help, a Medicare Part D Low-Income Subsidy (LIS) program
- Free medicine†
Help identifying resources for patients who do not have any form of healthcare coverage
- Help finding coverage
- Free medicine through the Pfizer Patient Assistance Program, or at a savings through the Pfizer Savings Program‡
Terms and Conditions
By enrolling in this co-pay offer, 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 this 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.
- With this card, eligible patients will pay a $0 co-pay per eligible monthly prescription, subject to a maximum amount of $25,000 per product per calendar year. The amount of any benefit is the difference between your co-pay and $0. After the annual maximum of $25,000 per product is reached, you will be responsible for the remaining monthly out-of-pocket costs. This card may not be redeemed more than once per 30 days. The average benefit is $924.21 per patient per year.
- This co-pay 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 co-pay card from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf.
- You are responsible for reporting use of the co-pay card 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 where prohibited by law.
- Card cannot be combined with any other savings, free trial, or similar offer for the specified prescription.
- Card will be accepted only at participating pharmacies.
- This card is not health insurance.
- Offer good only in the U.S. and Puerto Rico.
- Card is limited to 1 per person during this offering period and is not transferable.
- 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 6/30/2022.
If your pharmacy does not participate, you may be able to submit a request for a rebate in connection with this offer. Mail a copy of the patient’s pharmacy receipt indicating patient name, name of medication purchased, price paid, and date purchased, along with a copy of the patient’s Pfizer Oncology Together Co-Pay Savings Card, to:
Pfizer Oncology Together Co-Pay Savings Program
2250 Perimeter Park Drive, Suite 300
Morrisville, NC 27560
Pfizer Pledge Program
Pfizer stands by its commitment to patients
As part of its commitment, Pfizer is proud to offer the Pfizer Pledge Warranty Program for XALKORI (the “Program”).§ With this program, eligible patients can get their out-of-pocket costs for XALKORI refunded. See below for requirements. Pfizer Pledge is available to cash, commercial (those with employer-sponsored or private insurance), and Medicare Part D patients who discontinue XALKORI before the fourth 30-day supply is dispensed.
§Terms and Conditions apply.
Who is eligible for the Pfizer Pledge Program for XALKORI?
You are eligible if:
- XALKORI was prescribed for you to treat a condition for which it is FDA approved
- You have commercial or Medicare Part D insurance, or paid cash for XALKORI
- You used XALKORI according to the instructions provided by your physician
- Due to a clinical decision to discontinue, you stopped taking XALKORI before the 4th prescription was dispensed
- Your healthcare provider has provided a signed Physician Attestation Form noting the clinical rationale for discontinuation
Please refer to the Terms and Conditions to learn more.
How does the Pfizer Pledge Program for XALKORI work?
The Pfizer Pledge Warranty Program for XALKORI will refund eligible patients’ out-of-pocket costs as follows:
- If you are a cash, commercial, or Medicare Part D patient, you are eligible for the warranty if you receive your first dispensed prescription of XALKORI during the period June 1, 2021, through June 30, 2022.
- If you discontinue XALKORI for clinical reasons defined at the discretion of your healthcare provider before your pharmacy dispenses the fourth bottle (30-day supply) of XALKORI, you become eligible for a warranty claim payment.
- You can start the reimbursement process by downloading the Patient Warranty Claim Form and Patient Declarations and Authorizations Form or by calling 1-866-330-7902. The call center is open Monday-Friday, 7 AM-7 PM CT. The call center representative can walk you through the forms and provide instructions on how to complete them. If needed, someone who speaks your language may be able to help. The completed forms, together with your receipts for your out-of-pocket costs for XALKORI, can be mailed, emailed, or sent by fax.
- Your healthcare provider completes the Physician Attestation Form and submits it with your consent. Your healthcare provider may also give the signed form to you to submit.
- When the information provided is validated, the Program will reimburse you for what you paid out of pocket for XALKORI up to the first three 30-day supply bottles.
- Personal information will be kept confidential and will not be shared with anyone outside of the Program.
What can I do in advance to prepare?
If your first 30-day supply of XALKORI is dispensed on or after June 1, 2021, and you discontinue therapy before your fourth refill is dispensed, you may be eligible to receive a warranty payment. Following these 2 easy steps when you are purchasing XALKORI will make the process easier should you need to file a warranty claim:
- Keep or use a smartphone to take photos of the first 3 pharmacy receipts to document what you paid for XALKORI.
- Use a smartphone to take photos of the first 3 pill bottle labels for XALKORI to document the prescribing details.
Although you can obtain this documentation after starting XALKORI, it is suggested that you gather it when starting treatment.
Please download, fill out, and submit this form to start the reimbursement process. If you have questions, call 1-866-330-7902 Monday-Friday, 7 AM-7 PM CT for assistance.Download
Please read, sign, and submit this form. It is needed to process your claim.Download
Please give this form to your healthcare provider to fill out.Download
Please review the Terms and Conditions carefully before initiating the reimbursement process.
Terms and Conditions
Pfizer, Inc. (referred to as "us", "we" and similar terms) is proud to offer the Pfizer Pledge Warranty Program for XALKORI (the "Program") to each Patient (referred to as "you", "your" and similar terms) who meets the Eligibility Requirements and follows the Program Procedures described below, subject to all of the terms and conditions in this document (the "Terms"). You should carefully review these Terms.
Overview of Program
For Patients who meet the Eligibility Requirements, Pfizer will refund the out-of-pocket amount that you paid for up to the first three (3) bottles (30-day supply) of Xalkori, up to a maximum of $19,609 for each bottle (30-day supply) or an aggregate maximum of up to $58,827 (the “Maximum”). If your commercial insurance or Medicare and/or other payers (“Your Plan(s)”) paid for all or a portion of the cost of XALKORI, Pfizer will, on your behalf, refund to Your Plan(s) up to the Maximum that Your Plan(s) paid, less documented copayments provided by you. Payments to all parties must be equal to or less than the cost paid by each party and may reset Your Plan(s)’s out-of-pocket deductible and/or true out-of-pocket (“TrOOP”) cost in accordance with Your Plan(s)’s benefit design and Medicare requirements. The order of priority of warranty payments is first to you and then to Your Plan that is primary and then to Your Plan(s) that are secondary as determined by information provided by you and documented proof of payment that you provide to us. You are responsible for submitting proof of payment for you and for Your Plan(s). All claims payments will be reported to Your Plan(s) and to Medicare as required by law.
Medication Eligible for the Program
- XALKORI® (crizotinib) 200mg and 250mg
In order for you to be eligible to use the Program, you must satisfy all of the criteria listed below:
- You are a resident of the fifty (50) United States of America or the District of Columbia (the Program is void for any request made by anyone living outside the fifty (50) United States or the District of Columbia).
- You were prescribed XALKORI by your physician for an FDA-approved indication.
- You used XALKORI according to the instructions provided by your physician.
- You discontinued XALKORI for clinical reasons defined at the discretion of the physician. Discontinuation solely due to patient choice or affordability does not qualify for the Program.
- You, or you and Your Plan(s), paid, in whole or in part, for XALKORI. Patients whose XALKORI was covered, in whole or in part, by Medicaid or other federal healthcare programs (other than Medicare) are not eligible to use the Program.
- Your first bottle (30-day supply) of XALKORI must be dispensed on or after June 1, 2021 and on or before June 30, 2022 (the “Coverage Period”).
- You must discontinue using XALKORI prior to a pharmacy dispensing your fourth bottle (30-day supply) of XALKORI.
- You must submit all receipts for the amount of money you paid for XALKORI and documentation showing what Your Plan(s) paid for XALKORI, including your primary insurance, secondary insurance, and any other third-party payers (including patient assistance programs) to ensure accurate payment of claims. It is your responsibility to submit proof of payment towards the cost of XALKORI from Your Plan(s) before any warranty payments are dispersed.
- If you filled your first XALKORI prescription prior to or on December 31st, 2021, you must submit all Claims Information (as described below) within one hundred and twenty (120) days following the dispense date of your last bottle (30-day supply) of XALKORI. If you filled your first XALKORI prescription on or after January 1st, 2022, you must submit all Claims Information (as described below) within one hundred and eighty (180) days following the dispense date of your last bottle (30-day supply) of XALKORI.
Benefit Request Process
In order to be eligible for a refund under this Program, you must satisfy the requirements and submit the information below (the “Claims Information”), within one hundred and twenty (120) days following the dispense date of your last bottle (30-day supply) of XALKORI. If you filled your first XALKORI prescription on or before December 31st, 2021 OR within one hundred and eighty (180) days following the dispense date of your last bottle (30-day supply) of XALKORI if you filled your first XALKORI prescription on or after January 1st, 2022.
- Call 1-866-330-7902 and a representative will provide you with a Patient Warranty Claim Form, a Patient Declarations and Authorizations Form, and a Physician Attestation Form, or these forms may be downloaded from www.xalkori.com.
You will then need to return a fully completed and signed (i)
Patient Warranty Claim
Form, (ii) Patient Declarations and Authorizations Form, and
Attestation Form in
accordance with their instructions, which will include the
Patient Warranty Claim Form:
- Your name, date of birth, phone number, address, gender, and email address.
- Prescribing physician name, phone number and address.
- For each bottle (30-day supply), the dispensing pharmacy name, phone number and address.
For each bottle (30-day supply), Your Plan(s)’s
information and amounts paid by
Your Plan(s), including the following:
- For each primary insurer, secondary insurer and prescription Insurer, the insurance type, primary insurer name, phone number, address, policy/Medicare beneficiary ID#, group ID#, policyholder name, policyholder relationship, policyholder date of birth.
- A photocopy of each respective insurance card.
- Prescription information that includes: prescription #, Date of Dispense, Dose Dispensed (250mg or 200mg), number of pills dispensed, and days of supply.
- Proof of your out-of-pocket expense (e.g. receipts from your pharmacy)
- Documents showing payments made by Your Plan(s) (e.g. Commercial or Medicare Part D) including any secondary and/or other third-party payers (e.g. patient assistance programs), if applicable.
Patient Declarations and Authorizations Form which
- Attestation that you have discontinued XALKORI before the 4th dispense date of your last bottle (30-day supply) of XALKORI.
- Consent for the Pfizer Pledge.
- Consent to Receive Communication from our representative to process your claim.
- Authorization to share Health Information in order to process your claims.
- Acknowledgment of laws.
Physician’s Attestation Form completed and signed by
your prescribing physician
which includes the following information:
- Your name and date of birth.
- Prescribing physician name, phone number and address.
- Prescribing physician attestation that XALKORI was prescribed for on-label use, and the clinical rationale for discontinuance of XALKORI (no confirmatory documentation required).
- Patient Warranty Claim Form:
- If your Claims Information passes the verification process, we will notify you via telephone or email that you have been approved for coverage.
- If your Claims Information does not pass the verification process, we will notify you via email that your Request has been denied and the email will include the reason for the denial (such as, incomplete information, mismatched information, etc.). You will be given the opportunity to resubmit your Claims Information within thirty (30) days of the email notification.
Additional Terms and Conditions
By submitting your Claims Information under the Program, you are representing and warranting that you took the medication in accordance with the Instructions that were provided by your prescribing physician.
- We reserve the right to modify the processes, procedures, parameters, or other terms of the Program, or terminate the Program entirely, at any time, without prior notice to you. If we terminate the Program, we will: (i) continue to honor valid warranty claims related to initial doses of XALKORI, prescribed by your physician, dispensed during the Coverage Period. The current status of the Program and applicable terms are available at www.xalkori.com.
- We are refunding payments under this Program to you and Your Plan(s) based on the information provided by you. You are responsible for resolving any disagreements related to reimbursements made by us, on Your behalf, to Your Plan(s).
LIMITATION OF LIABILITY
IN NO EVENT, UNDER ANY CAUSE OF ACTION OF THEORY OF LIABILITY, SHALL PFIZER, ITS DISTRIBUTORS OR SUPPLIERS BE LIABLE TO YOU OR ANY THIRD PARTY FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, EXEMPLARY OR PUNITIVE DAMAGES, OF ANY NATURE WHATSOEVER, ARISING OUT OF OR IN CONNECTION WITH THE PROGRAM, EVEN IF PFIZER HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
NOTWITHSTANDING ANY DAMAGES THAT YOU MIGHT INCUR FOR ANY REASON WHATSOEVER INCLUDING, WITHOUT LIMITATION, ALL DAMAGES REFERENCED HEREIN AND ALL DIRECT OR GENERAL DAMAGES IN CONTRACT, TORT (INCLUDING NEGLIGENCE) OR OTHERWISE, THE ENTIRE AGGREGATE LIABILITY OF PFIZER AND ANY OF ITS DISTRIBUTORS AND/OR SUPPLIERS SHALL BE LIMITED TO THE MAXIMUM AMOUNT SET FORTH ABOVE FOR THE PRODUCT THAT IS SUBJECT TO THE PROGRAM. SOME STATES AND/OR JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, SO THE ABOVE LIMITATIONS OR EXCLUSIONS MAY NOT APPLY TO YOU. THE LIMITATIONS OF LIABILITY SET FORTH ABOVE SHALL APPLY TO THE MAXIMUM EXTENT PERMITTED UNDER APPLICABLE LAW.
ARBITRATION: Read the following arbitration provision (“Provision”) carefully. It limits certain of your rights, including your right to obtain relief or damages through court action.
To begin Arbitration, either you or we must make a written demand to the other party for arbitration for the applicable claim ("Claim"). The Arbitration will take place before a single arbitrator. It will be administered in keeping with the Expedited Procedures of the Commercial Arbitration Rules ("Rules") of the American Arbitration Association ("AAA") in effect when the Claim is filed. You may get a copy of these AAA's Rules by visiting www.adr.org. The filing fees to begin and carry out arbitration will be shared equally between you and us. This does not prohibit the arbitrator from giving the winning party their fees and expenses of the arbitration. Unless you and we agree, the arbitration will take place in the county and state where you live. The Federal Arbitration Act, 9 U.S.C. Ch. 1, et seq., will govern and not any state law on arbitration. YOU AGREE AND UNDERSTAND THAT this arbitration provision means that you give up your right to go to court on any Claim covered by this provision. You also agree that any arbitration proceeding will only consider your Claim. Claims by, or on behalf of, other individuals will not be arbitrated in any proceeding that is considering your Claims. THE DEGREE TO WHICH ARBITRATION CAN BE USED AS A DISPUTE RESOLUTION PROCESS FOR CONSUMER CLAIMS VARIES FROM STATE TO STATE, SO THIS ARBITRATION PROVISION MAY NOT APPLY TO YOU, DEPENDING ON YOUR STATE OF RESIDENCE. In the event this Arbitration provision is not approved by the appropriate state regulatory agency, and/or is stricken, severed, or otherwise deemed unenforceable by a court of competent jurisdiction, you and us specifically agree to waive and forever give up the right to a trial by jury. Instead, in the event any litigation arises between you and us, any such lawsuit will be tried before a judge, and a jury will not be impaneled or struck.