Paxlovid Co-Pay Savings Program

PAXCESSTM CO-PAY SAVINGS CARD REBATE

PAXLOVID CO-PAY SAVINGS PROGRAM INSTRUCTIONS: TERMS & CONDITIONS
If your pharmacy does not accept or cannot process your PAXLOVID™ By sending this rebate, you acknowledge that you
(nirmatrelvir tablets; ritonavir tablets) Co-Pay Savings Card, use this rebate form currently meet the eligibility criteria and will comply
to request reimbursement of your out-of-pocket co-pay costs for PAXLOVID.* with the terms and conditions described below:
1 Complete the rebate form below. Eligible commercially insured patients prescribed
PAXLOVID must be 12 years of age or older to redeem
2 Circle the medication name, the date, and the amount you paid for PAXLOVID the rebate. The patient’s primary diagnosis must be for
on your original pharmacy receipt. (Cash register receipt is not valid.) an FDA-approved or FDA-authorized indication. Patients
3 Ensure your pharmacy receipt includes the following information: are not eligible to participate in this program if they are
- Patient name and address enrolled in a state or federally funded insurance program,
- Pharmacy name, address, and phone number including but not limited to Medicare, Medicaid, TRICARE,
- Doctor or healthcare provider name, address, and phone number Veterans Affairs health care, a state prescription drug
- Prescription # (Rx #), fill date, drug name, strength, NDC #, and quantity assistance program, or the Government Health Insurance
Plan available in Puerto Rico (formerly known as “La
- Overall prescription price and co-pay/out-of-pocket expense paid
Reforma de Salud”). This rebate is not valid when the
4 Send in the completed rebate form along with your pharmacy receipt: entire cost of your prescription drug is eligible to be
reimbursed by your private insurance plan or other
By Mail: Attn: Claims Processing Department, IQVIA, Inc. private health or pharmacy benefit programs. Rebate
77 Corporate Dr., Bridgewater, New Jersey 08807 is not valid for cash-paying patients. The value of this
prescription is limited to $1,500 per use or the amount of
By Fax: 1-908-382-9209 (toll free) your prescription, whichever is less. Patient must submit
a completed rebate request form and the original, dated
COMPLETE AND RETURN THIS FORM: 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
NAME 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
ADDRESS
deduct the value received under this rebate from any
reimbursement request submitted to your private
CITY insurance plan, either directly by you or on your behalf.
Patient is responsible for reporting receipt of rebate to
STATE ZIP CODE PHONE 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.
EMAIL
You should not use this program if your private insurer
or health plan prohibits use of manufacturer savings
DATE OF BIRTH programs. This rebate is not valid where prohibited
by law. The benefit under the rebate is offered to, and
CO-PAY SAVINGS CARD MEMBER ID # DAYS SUPPLY intended for the sole benefit of, eligible patients and may
not be transferred to or utilized for the benefit of third
parties, including, without limitation, third party payers,
CLAIMANT MUST SIGN HERE pharmacy benefit managers, or the agents of either.
SIGNATURE DATE This rebate cannot be combined with any other external
savings, free trial or similar offer for the specified
prescription (including any program offered by a third
By my signature, I certify that I meet and agree to the party payer or pharmacy benefit manager, or an agent
terms and conditions listed on this rebate form, as well of either, that adjusts patient cost-sharing obligations,
as the eligibility requirements and restrictions that through arrangements that may be referred to as
I receive when I activate my card. “accumulator” or “maximizer” programs). This rebate
Don’t forget to sign is not health insurance. Offer good only in the U.S. and
To validate, you must sign and date this rebate form. and date the form. Your Puerto Rico. The rebate is limited to 1 per person during
The rebate check will arrive in 6-8 weeks. An additional signature is required this offering period and is not transferable. The rebate
rebate form is provided in the event it is necessary to for processing. may not be redeemed more than once per 30 days per
submit another request for reimbursement. patient. No other purchase is necessary. Data related
to your redemption of the rebate may be collected,
Please call 1-833-276-5308 analyzed, and shared with Pfizer, for market research and
QUESTIONS? Monday–Friday, 8:00 AM–8:00 PM ET other purposes related to assessing Pfizer’s programs.
Data shared with Pfizer will be aggregated
*Limits, terms and conditions apply, listed on this page.
and de-identified; it will be combined with data related
to other rebate redemptions and will not identify you.
Pfizer reserves the right to rescind, revoke, or amend
the program without notice. Rebate and Program
expires 12/31/2024.

For questions or additional support, call 1-833-276-5308

PP-C1D-USA-0373 © 2023 Pfizer Inc. All rights reserved. December 2023 or visit the PAXLOVID website at www.paxlovid.com.