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How can we help?

 

Access Patient Co-Pay Assistance

Select your patient's medication to find out if they’re eligible and to access a co-pay card.

HCP copay form

Please answer the following eligibility questions:

Pfizer Oncology Together Co-Pay Program for IV

The Pfizer Oncology Together Co-Pay Program for IV (“IV Co-Pay Program”) provides eligible patients with support for out-of-pocket drug costs, including co-pays, co-insurance, and deductibles. Limits, terms, and conditions apply.

HELP YOUR PATIENTS ENROLL

To get started, fax a completed enrollment form to 1-877-736-6506. Be sure to check the box for Intravenous (IV) Co-Pay Program and indicate if the patient will assign benefit to the healthcare provider.

enrollment form

For eligible, commercially insured patients

Co-pays may be as little as $0. Once the annual program limit is reached, the patient is responsible for the full co-pay.#

UP TO $25,000 PER CALENDAR YEAR

Program covers up to $25,000 per calendar year.**

No income requirements

There are no income requirements for patients to qualify.

OTHER RESOURCES

For information on claim submission or reimbursement processes, download the IV Co-Pay Program Brochure.

IV CO-PAY PROGRAM BROCHURE

To submit claims by fax or mail, complete and fax the Co-Pay Claim Form to 1-908-809-6241.

CO-PAY CLAIM FORM

For detailed instructions on Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA), or Electronic Data Interchange (EDI), go to the Forms & Resources page.

VIEW FORMS

For patients to be eligible for the IV Co-Pay Program, they must have commercial insurance that covers BESPONSA™ (inotuzumab ozogamicin) or MYLOTARG™ (gemtuzumab ozogamicin) (each referred to as “Product”) and they cannot be enrolled in a state or federally funded insurance program. Whether a co-pay expense is eligible for the IV Co-Pay Program benefit will be determined at the time the benefit is paid. Co-pay expenses must be in connection with a separately paid claim for Product administered in the outpatient setting.

#The IV Co-Pay Program will pay the co-pay and any deductible obligations for the Product up to the annual assistance limit of $25,000 per calendar year per patient.

**The IV Co-Pay Program provides assistance for eligible, commercially insured patients for co-pays, co-insurance, or deductibles incurred for the Product, up to $25,000 per calendar year. It does not cover or provide support for supplies, services, procedures, or any other physician-related services associated with Product treatment.

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