Pfizer enCompass Co-Pay Assistance Program for INFLECTRA · Pfizer enCompass HCP faxes or mails Patient receives mail the enrollment form to Pfizer enCompass, who will contact the

FDA-APPROVED

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INFLECTRA is a trademark of Pfizer Inc.Pfizer enCompass is a trademark of Pfizer Inc.

FDA-APPROVED

Pfizer enCompass® Co-Pay Assistance Program for INFLECTRA®

Guide to Enrollment Process

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FDA-APPROVED

FDA-APPROVED

The following steps outline the process to apply for and submit a claim to the co-pay assistance program when the healthcare provider (HCP) buys and bills.

• Users of the Co-Pay Assistance Program will first adjudicate the INFLECTRA claim with the patient’s primary insurance and then will submit a completed co-pay claim form to Pfizer enCompass along with a copy of the patient’s primary insurance explanation of benefits (EOB)

• Co-pay claims are paid based on the patient’s specific benefit type (ie, both medical and pharmacy benefits are eligible)• Flexible payment options allow the co-pay payment to go to the party who submits the co-pay claim (ie, HCP, patient, or specialty

pharmacy)

Please see samples of the Pfizer enCompass Enrollment Form and the Pfizer enCompass Co-Pay Assistance Program Claim Form on pages 7-10.

Pfizer enCompass completes a benefit verification (BV) to determine eligibility for the co-pay program. If approved, patient and HCP receive approval letter containing co-pay identification numbers.

Did the eligible patient complete

the Patient Consent and Attestation

(section 7) of the enrollment form?

Yes

No

HCP and eligible patient complete and sign the Pfizer

enCompass Enrollment

Form for INFLECTRA

HCP faxes or mails completed form to Pfizer enCompass

HCP faxes or mails

the enrollment form to Pfizer enCompass, who will contact the eligible patient to

complete section 7 of the enrollment

form

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Pfizer enCompass® Co-Pay Assistance Program for INFLECTRA® (infliximab-dyyb) for Injection

Enrollment Into the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA When INFLECTRA Is Acquired Through Buy-and-Bill

Guide to Enrollment and Claim SubmissionThis brochure provides an explanation of the enrollment process for the Pfizer enCompass® Co-Pay Assistance Program for INFLECTRA, including specifics for when INFLECTRA is acquired through the buy-and-bill or specialty pharmacy process. An overview of the process includes:

Program OverviewThe Pfizer enCompass Co-Pay Assistance Program for INFLECTRA provides eligible, commercially insured patients assistance of up to $20,000 per calendar year for claims received by the program. Eligible enrolled patients may pay as little as $0 for each INFLECTRA treatment. Federal and State health care beneficiaries not eligible. Private insurance only. The co-pay program covers only drug costs, not procedures, administration fees, or office visits.

Terms and ConditionsWith this program, eligible commercially insured patients may be responsible for as little as $0 co-pay per INFLECTRA treatment subject to a maximum benefit of $20,000 per calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. This program is not health insurance. No membership fees. This offer is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare or other federal or state healthcare programs. Only valid for private insurance. This offer is not valid for prescriptions that are eligible to be reimbursed in whole by private insurance plans or other health or pharmacy benefit programs. For more information about the Pfizer enCompass Co-Pay Assistance Program, call Pfizer enCompass at 1-844-722-6672. See full Terms and Conditions on page 11.

If the patient assigns co-pay benefits to their HCP, (see section 7 of enrollment form), the HCP office may follow the steps below to submit claims to the co-pay program for reimbursement on the patient’s behalf

HCP completes and submits the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA Claim Form and copies of primary and secondary insurance EOBs to the program via EDI, fax, or mail

Patient receives treatment with INFLECTRA and HCP submits the INFLECTRA claim to the patient’s primary insurance

HCP receives fax notification of status of claim. If the claim is approved, the co-pay payment is issued to HCP via check or EFT, (if registered) within 7 to 10 business days

Claim Submission Option 1

If the patient does not assign co-pay benefits to their HCP, (see section 7 of enrollment form), the patient may follow the steps below to submit claims to the co-pay program for reimbursement

Patient completes and submits the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA Claim Form and copies of primary and secondary insurance EOBs to the program by mail or fax

Patient receives treatment with INFLECTRA and pays co-pay or coinsurance to HCP

Patient receives mail notification of status of claim. If the claim is approved, the co-pay payment is issued to the patient via check within 7 to 10 business days

Claim Submission Option 2

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In certain cases, INFLECTRA is dispensed by an SP when INFLECTRA is covered under the patient’s prescription benefit or when a patient’s insurance requires SP dispensing. The following steps serve as a guide for enrolling in the co-pay program and submitting a claim for reimbursement when INFLECTRA is accessed through an SP.

Pfizer enCompass completes a BV to determine eligibility for the co-pay program. If approved, patient and HCP receive approval letter containing co-pay identification numbers. HCP or patient provide the co-pay identification card to the SP.

SP processes the INFLECTRA claim through the patient’s primary and secondary insurance and then processes the co-pay claim through the Pfizer enCompass Co-PayAssistance Program

HCP or eligible patient completes and signs the Pfizer enCompass Enrollment Form

Did the eligible patient complete the Patient Consent and Attestation (section 7) of the enrollment form?

Yes No

HCP faxes or mails completed form to Pfizer enCompass

HCP faxes or mails the enrollment form to Pfizer enCompass, who will

contact the eligible patient to complete section 7 of the

enrollment form

SP receives the prescription for INFLECTRA and thepatient co-pay identification card information from theHCP or patient to process the co-pay claim

SP receives payment from the co-pay program via standard SP payment method

Enrollment Into the Pfizer enCompass® Co-Pay Assistance Program for INFLECTRA When INFLECTRA Is Acquired Through a Specialty Pharmacy (SP) and the SP Bills for INFLECTRA

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FDA-APPROVED

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Pfizer is committed to offering reimbursement and patient support for patients who have been prescribed INFLECTRA. As part of this commitment, we have developed Pfizer enCompass.

Pfizer enCompass is available to provide:• Reimbursement support available to minimize patient access barriers• Patient support offered for eligible uninsured and underinsured Pfizer enCompass patients

Reimbursement and patient support information are also available at www.pfizerencompass.com.

If you have questions about the Co-Pay Assistance Program for INFLECTRA or would like to know more about other patient support options available through Pfizer enCompass, please contact a Pfizer enCompass Access Counselor or visit www.pfizerencompass.com for more information.

1-844-722-6672Monday–Friday

9 am–8 pm ET

Fax 1-844-482-4482

Pfizer enCompassP.O. Box 220040

Charlotte, NC 28222

Website for Healthcare Providers (HCPs) and Patients

www.pfizerencompass.com

Pfizer enCompass® Support

FDA-APPROVED

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Pfizer enCompass has a secure provider portal at www.pfizerencompassonline.com for HCPs and their staff. The portal allows the convenience of online, real-time access to Pfizer enCompass support and resources through electronic submission of requests for a variety of Pfizer support, including patient insurance BVs and tracking the progress of patient requests.

To get started, select one of the following options:

Visit www.pfizerencompassonline.com, and click “Register Now”

Pfizer enCompass® Provider Portal

Call Pfizer enCompass at 1-844-722-6672 to speak to an Access Counselor about getting started in the Provider Portal

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24/7 access to information and resources

The Pfizer enCompass website is a centralized resource to access information about Pfizer enCompass reimbursement and patient support as well as important information on coverage, coding, and payment of Pfizer’s Food and Drug Administration (FDA)-approved biosimilar products.

The following can be accessed through the Pfizer enCompass website:

To get started, visit www.pfizerencompass.com

Introducing the Pfizer enCompass Website

Reimbursement support information and resources

Billing and coding information for each FDA-approved Pfizer biosimilar

Pfizer enCompass information including co-pay assistance and free drug assistance for eligible patients

Brochures and FAQs along with downloadable and writeable PDF versions of forms

Direct link to the secure Pfizer enCompass Provider Portal

FDA-APPROVED

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Pfizer Inc. Pfizer enCompass® Enrollment Form for INFLECTRA® (infliximab-dyyb) for Injection

Please complete and fax this form to 1-844-482-4482 or mail to Pfizer Inc. (“Pfizer”) at Pfizer enCompass, PO Box 220040, Charlotte, NC 28222 For assistance call: 1-844-722-6672, Monday–Friday, 9 am–8 pm ET

For enrollment into the Pfizer Patient Assistance Program or Drug Replacement Program, complete the Pfizer Patient Assistance Program Application available at www.pfizerencompass.com or by calling Pfizer enCompass.

By enrolling in Pfizer enCompass, patients will receive various support and information to help access Pfizer medicine, which may include the following, depending on the program (collectively, “Patient Support Activities”):

*NAME (FIRST, MIDDLE INITIAL, LAST) *SEX MALE FEMALE

*STREET ADDRESS *CITY *STATE *ZIP

*DATE OF BIRTH (MM/DD/YY) EMAIL *PHONE

1. PATIENT INFORMATION (TO BE COMPLETED BY PATIENT) *INDICATES REQUIRED FIELDS

LANGUAGE PREFERENCE

*INSURANCE NAME *INSURANCE PHONE *POLICY/GROUP NUMBER

*POLICY HOLDER NAME

PRIMARY DIAGNOSIS CODE

SECONDARY DIAGNOSIS CODE

List Current/Prior TreatmentsTreatment Length (mm/yyyy) From To

1. Methotrexate Y N

2.

3.

4.

5.HEP B TEST DATE POS NEG

Please list all current treatments to the right and any prior treatments associated with the indications provided above.

TB/PPD TEST DATE POS NEG

• Providing benefits investigations/verification and reimbursement support, including: - Assistance with prior authorization requirements from my insurer - Assistance with appealing any denial from my insurer

• Determining my eligibility for and helping me access co-pay support or free drug programs

• Communicating with my Healthcare Providers about a Pfizer medicine and Patient Support Activities

• Providing me with financial assistance resources and information if I’m eligible• Providing me with disease management and other educational materials, as well as

information about Pfizer’s products, services, and programs, and may include sending me surveys about my experience with Pfizer products, services, and programs

PATIENT CAREGIVER

CHECK HERE IF PATIENT DOES NOT HAVE INSURANCE CHECK HERE IF PATIENT HAS SECONDARY INSURANCE

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Benefit verification and/or prior authorization support (Complete sections 1-4, 8)

Pfizer enCompass Co-Pay Assistance Program (Complete sections 1-8)

Referral for Interim Assistance (Complete sections 1-5, 8)

Please check the appropriate box(es) and complete the enrollment form

PLEASE INCLUDE A COPY OF THE FRONT AND BACK OF THE PATIENT’S INSURANCE CARD(S)

CAREGIVERNAME

CAREGIVERPHONE

2. CLINICAL INFORMATION

3. INSURANCE INFORMATION (TO BE COMPLETED BY PATIENT OR HEALTHCARE PROVIDER) *INDICATES REQUIRED FIELDS

PRIMARY INSURANCE

*POLICY HOLDER RELATIONSHIP TO PATIENT

*POLICY HOLDER DATE OF BIRTH (MM/DD/YY)

PREFERRED SPECIALTY PHARMACY

SELF-DISPENSING PHARMACY

The patient identified above prefers use of the Specialty Pharmacy indicated above. I authorize Pfizer and its affiliates, agents, representatives, and service providers to fax this prescription to the Specialty Pharmacy designated above, provided it is approved by this patient’s plan. If the Specialty Pharmacy designated is not a plan-approved Specialty Pharmacy, then fax to a Specialty Pharmacy approved by this patient’s plan. If there is no preferred Specialty Pharmacy indicated, then fax to any Specialty Pharmacy approved by this patient’s plan.

*PREFERRED SPECIALTY PHARMACY NAME

PRESCRIPTION INSURANCE NAME PRESCRIPTION POLICY ID NUMBER

PRESCRIPTION GROUP ID NUMBER PRESCRIPTION BIN PRESCRIPTION PCN

PRESCRIPTION INSURANCE

*INSURANCE NAME *INSURANCE PHONE *POLICY/GROUP NUMBER

*POLICY HOLDER NAME

SECONDARY INSURANCE

*POLICY HOLDER RELATIONSHIP TO PATIENT

*POLICY HOLDER DATE OF BIRTH (MM/DD/YY)

Tip: Indicate the support you are requesting and complete all associated

sections

Tip: Email address for the Administering Provider

and Billing Address Sections must be to a specific contact since

co-pay payment notices will be sent via email

This enrollment form is a 5-page form that must be completed and signed on by the HCP and eligible patient to complete the enrollment process and apply for co-pay assistance.

Use a Single Pfizer enCompass® Enrollment Form to Request Co-Pay Assistance and Other Pfizer enCompass Support

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Tip: Complete the Administering Provider

and Billing Address sections in their entirety if the Referring Provider is not administering or

billing for the drug

Tip: Patient must sign this section to be

contacted by Pfizer enCompass

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PRINT NAME OF PATIENT* PATIENT SIGNATURE DATE

6. PATIENT CONSENT TO RECEIVE COMMUNICATIONS

By signing this form, I agree to communications from Pfizer, Pfizer enCompass, and/or parties acting on their behalf to determine my eligibility and provide benefits verification, prior authorization/appeals assistance, and financial assistance resources and information, such as co-pay support or free drug programs, and for other non-marketing purposes. I agree to be contacted by Pfizer, Pfizer enCompass, or parties working on their behalf for these purposes using an autodialer or prerecorded voice at the telephone number(s) provided. If I have a caregiver, he or she has also agreed to receive such communications from Pfizer, Pfizer enCompass, and/or parties acting on their behalf for the purposes described above, and I hereby give my permission for Pfizer, Pfizer enCompass, and/or parties acting on their behalf to contact my caregiver for such purposes. I understand that I (and, if applicable, my caregiver) can opt out of these communications at any time by contacting Pfizer enCompass at 1-844-722-6672, Monday–Friday, 9 am–8 pm ET.

TERMS AND CONDITIONSBy using this program, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions below:

The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA is not valid for patients that are enrolled in a state or federally funded insurance program, including but not limited to Medicare, Medicaid, TRICARE, Veteran 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”). Program offer is not valid for cash-paying patients. With this program, eligible patients may pay as little as $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. Patient must have private insurance with coverage of INFLECTRA. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other private health or pharmacy benefit programs. You must deduct the value of this assistance 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 program to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the program, as may be required. You should not use the program if your insurer or health plan prohibits use of manufacturer co-pay assistance programs. This program is not valid where prohibited by law. This program cannot be combined with any other savings, free trial or similar offer for the specified prescription. This program is not health insurance. This program is good only in the U.S. and Puerto Rico. This program 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 program assistance 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 assistance redemptions and will not identify you. Pfizer reserves the right to rescind, revoke or amend this program without notice. This program may not be available to patients in all states. For more information about Pfizer, visit www.pfizer.com. For more information about the Pfizer enCompass Co-Pay Assistance Program, call Pfizer enCompass at 1-844-722-6672, or write to Pfizer enCompass Co-Pay Assistance Program, P.O. Box 220040, Charlotte, NC 28222. Program terms will expire at the end of each calendar year. Before the calendar year ends, you will receive information and eligibility requirements for continued participation.

*STREET ADDRESS *CITY *STATE *ZIP

*OFFICE PHONE OFFICE FAX *OFFICE CONTACT

4. HEALTHCARE PROVIDER INFORMATION (TO BE COMPLETED BY HEALTHCARE PROVIDER. ALL FIELDS MUST BE COMPLETED) *INDICATES REQUIRED FIELDS

*PRACTICE/ INSTITUTION NAME

*SPECIALTY*PRESCRIBER NAME (FIRST/MI/LAST)

*OFFICE CONTACT EMAIL

*OFFICE CONTACT PHONE NUMBER

*GROUP TAX ID NUMBER

*STATE LICENSE NUMBER

*PRACTICE NAME *OFFICE CONTACT

*ADDRESS *CITY *STATE *ZIP

*PHONE *FAX *EMAIL

ADMINISTERING PROVIDER INFORMATION (IF DIFFERENT FROM REFERRING PROVIDER)ADMINISTERING PROVIDER ADMINISTERS AND OVERSEES THE PRODUCT INFUSION *INDICATES REQUIRED FIELDS

*SPECIALTY*ADMINISTERING PROVIDER NAME (FIRST/MI/LAST) *NPI # *STATE LICENSE #

* PATIENT NAME (FIRST, MIDDLE INITIAL, LAST)

*PRACTICE BILLING OFFICE NAME *PRACTICE BILLING OFFICE CONTACT

*PRACTICE BILLING ADDRESS *CITY *STATE *ZIP

*PRACTICE BILLING PHONE *EMAIL

5. BILLING ADDRESS FOR PAYMENT FROM THE PFIZER enCOMPASS CO-PAY ASSISTANCE PROGRAM, IF DIFFERENT FROM ADMINISTERING PROVIDER *INDICATES REQUIRED FIELDS

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*Patient name or name of personal representative. If personal representative of patient, please complete the fields below.

SIGNATURE OF PERSONAL REPRESENTATIVE DATE DESCRIPTION OF AUTHORITY

FDA-APPROVED

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Tip: The HCP’s signature is required for the

enrollment form to be processed and to receive

any support through Pfizer enCompass®

Tip: Eligible patient signature is REQUIRED if

enrolling into the Co-Pay Program

Tip: The patient must also review and respond “Yes” or “No” to the statements

about co-pay payment and healthcare coverage

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* PATIENT NAME (FIRST, MIDDLE INITIAL, LAST)

8. HEALTHCARE PROVIDER HIPAA AND TELEPHONE CONSUMER PROTECTION ACT (TCPA) ATTESTATION (TO BE COMPLETED BY HEALTHCARE PROVIDER)

SIGNATURE OF HEALTHCARE PROVIDER DATE

By my signature, I certify that I have obtained any and all authorizations and consents from the patient or the patient’s authorized personal representative necessary under HIPAA and state law to release protected health information, including that contained on this form, to Pfizer and its employees or agents for purposes relating to Pfizer’s patient support programs, including, assisting the patient with benefits verification, prior authorization/appeals assistance, financial assistance resources and information, such as co-pay support or free drug programs, for which the patient may be eligible, and other support for INFLECTRA.

I certify that I have obtained consent from the patient or the patient’s caregiver to be contacted by Pfizer, Pfizer enCompass, and/or parties acting on their behalf using an autodialer or prerecorded voice at the telephone number(s) provided regarding the purposes described above and for other non-marketing purposes. I also give my permission to receive calls related to these services from Pfizer, Pfizer enCompass, and parties acting on their behalf, including calls made with an autodialer or prerecorded voice at the phone number(s) provided.

I authorize the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA to provide payment directly to my healthcare provider, and not to me, for my out-of-pocket drug costs for INFLECTRA. I authorize my healthcare provider to contact the Program on my behalf to initiate payment for services after they have been rendered. I understand that I will be responsible for any out-of-pocket expenses for INFLECTRA if (1) my healthcare provider does not request payment within 120 days of the issue date on my Explanation of Benefits (EOB), or (2) if I am deemed ineligible for reimbursement from the Program. To be eligible for this program, you must be commercially insured and not be enrolled in a state- or federally funded insurance program. Please see full terms and conditions.

Co-Pay Program Consent and Attestation: The checkboxes below must be completed if you are requesting enrollment in the Pfizer enCompass Co-Pay Assistance Program.

PRINT NAME OF PATIENT* PATIENT SIGNATURE DATE


SIGNATURE OF PERSONAL REPRESENTATIVE DATE DESCRIPTION OF AUTHORITY

7. PATIENT CONSENT AND ATTESTATION IF REQUESTING CO-PAY ASSISTANCE

Yes No

I attest that I am not 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 program, or the Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”). I attest that I am not over 65 years of age and retired. I attest that I do not receive Social Security Disability (SSDI) or any other Social Security Administration (SSA) benefit. I attest that I do not have End Stage Renal Disease (ESRD). I further attest that I am not active duty military nor are any of my immediate family members.

Yes No

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DISCLAIMERInsurance verification is the ultimate responsibility of the provider. Benefit information provided by Pfizer enCompass is not a guarantee of insurance coverage or reimbursement. All benefit information is subject to the insured patient’s plan at the time services are rendered. Under no circumstances shall Pfizer enCompass be held responsible or liable for payment of any claims, benefits, or cost. Any coding information obtained from Pfizer enCompass is provided for informational purposes only, is subject to change, and should not be construed as legal advice. Providers should exercise independent clinical judgment when selecting codes and submitting claims to accurately reflect the services and products furnished to the specific patient.

FDA-APPROVED

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PATIENT AUTHORIZATION TO SHARE HEALTH INFORMATION

By signing this form, I give my permission for my physicians, pharmacies, laboratories, and other healthcare providers (“Healthcare Providers”) and my health insurers to share my health information with Pfizer Inc., the Pfizer Patient Assistance Foundation, Pfizer affiliates, and its vendors (collectively, “Pfizer”). I understand that my health information includes information relating to my medical condition, treatment, and insurance coverage, as well as identifying information about me (including, for example, my name, address, and date of birth). My health information will be shared with Pfizer so that Pfizer may provide me with various support and information to help me access a Pfizer medicine, which may include the following, depending on your program (collectively, “Patient Support Activities”):

• Providing benefits investigations/verification and reimbursement support, including:

- Assistance with prior authorization requirements from my insurer

- Assistance with appealing any denial from my insurer

• Determining my eligibility for and helping me access co-pay support or free drug programs

• Sending me a device and starter kit (where appropriate)

• Communicating with my Healthcare Providers about a Pfizer medicine and Patient Support Activities

• Providing me with financial assistance resources and information if I’m eligible

• Providing me with disease management and other educational materials, as well as information about Pfizer’s products, services, and programs, and may include sending me surveys about my experience with Pfizer products, services, and programs

Pfizer also may use my health information for quality assurance purposes and to evaluate and improve their operations and services. I understand that I do not have to sign this form, and choosing not to sign will not affect my ability to receive treatment from my Healthcare Providers or payment from my health insurer. However, if I do not sign this form, Pfizer enCompass may not be able to provide me with assistance.

I understand that once my health information is shared, it may no longer be protected by federal privacy law. However, Pfizer agrees to protect my health information and to use it for the purposes described in this form or as required or permitted by law. Select pharmacies may receive remuneration from Pfizer in exchange for my health information and/or for any Patient Support Activities provided to me.

I understand that this form will remain in effect for 4 years from the date of my signature unless I provide written notice that I would like to withdraw my approval to share my health information sooner. If I would like to withdraw my approval, I may contact my physician or I may contact Pfizer enCompass at PO Box 220040, Charlotte, NC 28222, 1-844-722-6672, Monday–Friday, 9 am–8 pm ET. This withdrawal will not affect the use or sharing of my health information that took place before I withdrew my approval. I understand I may receive a copy of this form.

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PP-PAT-USA-1026 © 2019 Pfizer Inc. All rights reserved. Printed in USA/May 2019

PATIENT AUTHORIZATION TO SHARE HEALTH INFORMATION

PRINT NAME OF PATIENT* PATIENT SIGNATURE

I also give my permission to receive communications from Pfizer, Pfizer enCompass, and parties acting on their behalf, including calls made with an autodialer or prerecorded voice at the phone number(s) provided to determine my eligibility and provide benefits verification, prior authorization/appeals assistance, and financial assistance resources and information, such as co-pay support or free drug programs, and for other non-marketing purposes. If I have a caregiver, he or she has also agreed to receive

such communications from Pfizer, Pfizer enCompass, and/or parties acting on their behalf for the purposes described above, and I hereby give my permission for Pfizer, Pfizer enCompass, and/or parties acting on their behalf to contact my caregiver for such purposes. I understand that I (and, if applicable, my caregiver) can opt out of these communications at any time by contacting Pfizer enCompass at 1-844-722-6672, Monday–Friday, 9 am–8 pm ET.

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DATE

SIGNATURE OF PERSONAL REPRESENTATIVE

DESCRIPTION OF AUTHORITY DATE

Tip: Patient must sign the authorization to receive

support from Pfizer enCompass.

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FDA-APPROVED

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HCPs have 3 ways to submit claims to the co-pay assistance program for INFLECTRA:

1. Fax or mail a Pfizer enCompass Co-Pay Assistance Program Claim Form and EOB documents

2. Utilize your practice’s billing software

3. Utilize Claim.MD

a. Upload claims directly

b. Submit claims manually

c. Submit claims via secure file transfer protocol (sFTP)

Tip: A sample completed Pfizer enCompass Co-Pay Assistance Program Claim Form is found on page 10. A co-pay claim form is submitted after the patient is approved and enrolled in the INFLECTRA Co-Pay Assistance Program. The HCP must submit copies of EOBs for INFLECTRA claims received from the patient’s primary and secondary insurance (if applicable) with the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA Claim Form.

Submission of Claims to the Pfizer enCompass® Co-Pay Assistance Program When the HCP Purchases and Bills for the Drug (Buy-and-Bill Scenario)

Terms and ConditionsBy using this program, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions below:

The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA is not valid for patients that 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”). Program offer is not valid for cash-paying patients. With this program, eligible patients may pay as little as $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. Patient must have private insurance with coverage of INFLECTRA. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other private health or pharmacy benefit programs. You must deduct the value of this assistance 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 program to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the program, as may be required. You should not use the program if your insurer or health plan prohibits use of manufacturer co-pay assistance programs. This program is not valid where prohibited by law. This program cannot be combined with any other savings, free trial or similar offer for the specified prescription. This program is not health insurance. This program is good only in the U.S. and Puerto Rico. This program 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 program assistance 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 assistance redemptions and will not identify you. Pfizer reserves the right to rescind, revoke or amend this program without notice. This program may not be available to patients in all states. For more information about Pfizer, visit www.pfizer.com. For more information about the Pfizer enCompass Co-Pay Assistance Program, call Pfizer enCompass at 1-844-722-6672, or write to Pfizer enCompass Co-Pay Assistance Program, P.O. Box 220040, Charlotte, NC 28222. Program terms will expire at the end of each calendar year. Before the calendar year ends, you will receive information and eligibility requirements for continued participation.

FDA-APPROVED

®

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The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA® (infliximab-dyyb) for Injection provides eligible commercially insured patients with assistance of up to $20,000 per calendar year. Eligible enrolled patients may pay as little as $0 for each INFLECTRA treatment. Federal and State health care beneficiaries not eligible. Private insurance only. The co-pay program covers only drug costs, not procedures, administration fees, or office visits. Please see full Terms and Conditions below.

If there are any changes to the patient’s provider, administering infusion provider, insurance, or contact information, call Pfizer enCompass at 1-844-722-6672 prior to the submission of the co-pay claim form.

Access Counselors are available Monday–Friday, 9 am–8 pm ET.

ADMINISTERING PROVIDER (Enter the name of the administering provider or infusion center)

PRACTICE NAME

UPDATED INSURANCE DETAIL (if the insurance has changed since last submission)

Pfizer enCompass Co-Pay Assistance Program | CLAIM FORMAll fields marked with an asterisk (*) are required.

*ZIP CODE *DATE OF BIRTH *DATE OF SERVICE *PATIENT OUT-OF-POCKET AMOUNT FOR INFLECTRA

PATIENT

*PATIENT FIRST NAME *PATIENT LAST NAME PATIENT MIDDLE INITIAL

*PATIENT GROUP NUMBER (ie, EX00000000) (from program ID card on the approval letter)

*PATIENT MEMBER ID NUMBER (11-digit ID from program ID card on the approval letter)

Male Female*GENDER

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PP-IFA-USA-0528 © 2019 Pfizer Inc. All rights reserved. Printed in USA/May 2019

Terms and Conditions: By using this program, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions below:

The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA is not valid for patients that are enrolled in a state or federally funded insurance program, including but not limited to Medicare, Medicaid, TRICARE, Veteran 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. Program offer is not valid for cash-paying patients. With this program, eligible patients may pay as little as $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. Patient must have private insurance with coverage of INFLECTRA. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other private health or pharmacy benefit programs. You must deduct the value of this assistance 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 program to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the program, as may be required. You should not use the program if your insurer or health plan prohibits use of manufacturer co-pay assistance programs. This program is not valid where prohibited by law. This program cannot be combined with any other savings, free trial or similar offer for the specified prescription. This program is not health insurance. This program is good only in the U.S. and Puerto Rico. This program 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 program assistance 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 assistance redemptions and will not identify you. Pfizer reserves the right to rescind, revoke or amend this program without notice. This program may not be available to patients in all states. For more information about Pfizer, visit www.pfizer.com. For more information about the Pfizer enCompass Co-Pay Assistance Program, call Pfizer enCompass at 1-844-722-6672, or write to Pfizer enCompass Co-Pay Assistance Program, P.O. Box 220040, Charlotte, NC 28222. Program terms will expire at the end of each calendar year. Before the calendar year ends, you will receive information and eligibility requirements for continued participation.

PRIMARY INSURANCE BIN FOR PHARMACY BENEFIT

PRIMARY INSURANCE PCN FOR PHARMACY BENEFIT

PRIMARY INSURANCE NAME

PRIMARY INSURANCE GROUP # FOR PHARMACY BENEFIT

PRIMARY INSURANCE ID FOR PHARMACY BENEFIT

PRIMARY INSURANCE GROUP # FOR MEDICAL BENEFIT

*PROVIDER FIRST NAME *PROVIDER LAST NAME

Regional Medical Center

01234

EC30005006 01234567891

05/11/1999 05/01/2019 500.00

Smith

Holly Doe, MD

PRIMARY INSURANCE GROUP ID FOR MEDICAL BENEFIT

Jane

Patients may be eligible for this offer if they: • Have commercial insurance that covers INFLECTRA• Are not enrolled in a state or federally funded insurance program

CLAIMS PROCESS NOTE: Patients must be enrolled in the Pfizer enCompass Co-Pay Assistance Program. Please submit the following:

• A completed claim form within 120 days of the issue date on the patient’s Explanation of Benefits (EOB)

• A copy of the EOB or dated pharmacy receipt if the prescription was filled by a pharmacy

• The group and member ID information on the Pfizer enCompass Co-Pay Assistance Program identification card (provided on the approval letter)

Submit claims via mail or fax: Mail: Pfizer enCompass Co-Pay Assistance Program P.O. Box 10812, Fairfield, NJ 07004Fax: 1-908-809-6240

Pfizer enCompass® Co-Pay Assistance Program CLAIM FORM for INFLECTRA® (infliximab-dyyb) for InjectionPlease fax the completed form to 1-908-809-6240If you have questions, please call 1-844-722-6672

SAMPLE

Submission of INFLECTRA Co-Pay Claims Using the Claim Form: Sample Completed Form

FDA-APPROVED

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PP-IFA-USA-0554 © 2019 Pfizer Inc. All rights reserved. July 2019

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Documents

Pfizer enCompass Co-Pay Assistance Program for INFLECTRA · Pfizer enCompass HCP faxes or mails Patient receives mail the enrollment form to Pfizer enCompass, who will contact the