TERMS AND CONDITIONS

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

• Patients are not eligible to use this card if they 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. Offer is not valid for cash-paying patients. Patients are responsible for as little as a $5 monthly copayment based upon program utilization. The value of this Copay Card is limited to a maximum of $20,000 per calendar year.
• This copay card 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.
• You must deduct the value of this copay card 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 copay card to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the copay card, as may be required. You should not use the copay card if your insurer or health plan prohibits use of manufacturer copay cards.
• You must be 18 years of age or older to redeem the copay card.
• This copay card is not valid where prohibited by law.
• Copay card cannot be combined with any other savings, free trial or similar offer for the specified prescription.
• Copay card will be accepted only at participating pharmacies.
• If your pharmacy does not participate, you may be able to submit a request for a rebate in connection with this offer.
• This copay card is not health insurance.
• Offer good only in the U.S. and Puerto Rico.
• Copay card is limited to 1 per person during this offering period and is not transferable.
• A copay card may not be redeemed more than once per 30 days per patient.
• No other purchase is necessary.
• No membership fee.
• Data related to your redemption of the copay card 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 copay card redemptions and will not identify you.
• Pfizer reserves the right to rescind, revoke or amend this offer without notice.
• Offer expires 12/31/2023.

For more information, visit our website www.somavert.com, call 1-800-645-1280 or visit Pfizer.com. SOMAVERT Copay Support Program, PO Box 220746, Charlotte, NC 28222-0746

• Dedicated PCC support:
  • The Pfizer Bridge Program* assigns a dedicated Patient Care Consultant (PCC) to assist with insurance coverage and provide your patients with reimbursement support throughout therapy
  • Each PCC is knowledgeable about regional payers and individual plans and can help research coverage for your SOMAVERT patients when their insurance changes
• Patient Assistance Program: Provides qualifying uninsured and government insured patients with SOMAVERT at no cost^†
• Self-injection training: Patients can get one-on-one, virtual or in-home training by qualified nurses. To request training for your patient during enrollment, check the "Patient Injection Training Requested" box on the SOMAVERT Patient Enrollment Form

• Help patients enroll in the Pfizer Bridge Program 
• Conduct electronic Benefits Verifications
• Prepare and submit electronic Prior Authorization requests 
• Provide e-signatures for SOMAVERT prescriptions 
• Track patient's status and receive notifications 
• Access digital forms and resources