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 December 31, 2021.
- 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.