Pfizer Dermatology Patient Access™ Copay Savings Card Rebate Terms and Conditions

By sending this rebate, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

• Patients are not eligible to participate in this program 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").
• This rebate 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.
• For CIBINQO®, you will receive a maximum benefit of $15,000 per calendar year, which is defined by the date of enrollment through December 31st of the enrollment year, and may pay as little as $0 per month copay. After a maximum of $15,000, you will be responsible for paying the remaining monthly out-of-pocket costs.
• For LITFULO, you will receive a maximum benefit of $15,000 per calendar year, which is defined by the date of enrollment through December 31st of the enrollment year, and may pay as little as $0 per month copay. After a maximum of $15,000, you will be responsible for paying the remaining monthly out-of-pocket costs.
• For EUCRISA, you will receive a maximum benefit of $3880 per calendar year, which is defined by the date of enrollment through December 31st of the enrollment year, and may pay as little as $10 per tube. After a maximum of $3880, you will be responsible for paying the remaining monthly out-of-pocket costs.
• Patient must submit a completed rebate request form and the original, dated store-identified receipt accompanying your prescription as proof of purchase to the address provided on this form. Receipt will not be returned. See instructions on rebate request form.
• Rebate will be mailed to patients approximately 6 to 8 weeks after receipt of required documentation or earlier, as required by law.
• You must deduct the value received under this rebate from any reimbursement request submitted to your private insurance plan, either directly by you or on your behalf.
• Patient is responsible for reporting receipt of rebate to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription for which the patient receives a rebate, as may be required. You should not use this program if your private insurer or health plan prohibits use of manufacturer coupons, copay cards, debit cards, or similar savings programs.
• This rebate is not valid where prohibited by law.
• This rebate cannot be combined with any other savings, free trial, or similar offer for the specified prescription.