REBATE PROGRAM INSTRUCTIONS:
If your pharmacy does not accept or cannot process your XELJANZ® (tofacitinib)
Co-Pay Savings Card, use this Rebate Form to request reimbursement of your
out-of-pocket co-pay costs for XELJANZ.*
➊
Complete the rebate form below.
➋
Circle the medication name, the date, and the amount you paid
for XELJANZ on your original pharmacy receipt.
(Cash register receipt is not valid.)
➌
Send in the completed rebate form along with your pharmacy receipt:
By mail: Co-Pay Savings Program # 99992179
2250 Perimeter Park Drive, Suite 300
Morrisville, NC 27560
By fax: 1-888-668-8137 (toll-free)
By email:
Go to
www.xeljanzrebate.com
to download an electronic
rebate form. Complete and email the rebate form and your
pharmacy receipt to xeljanzsupport@trialcard.com.
COMPLETE AND RETURN THIS FORM:
NAME
ADDRESS
CITY
STATE ZIP CODE PHONE
EMAIL
CO-PAY SAVINGS CARD MEMBER ID # DAYS SUPPLY
SIGNATURE DATE
By my signature, I certify that I meet and agree to the
terms and conditions listed on this rebate form, as well
as the eligibility requirements and restrictions that I
received when I activated my card.
To validate, you must sign and date this rebate form.
The rebate check will arrive in 6-8 weeks. An additional
rebate form is provided in the event it is necessary to
submit another request for reimbursement.
*Limits, terms and conditions apply, listed on this page.
Don’t forget to sign
and date the form. Your
signature is required
for processing.
Please call 1-844-935-5269, Monday–Friday,
8:00 AM–8:00 PM ET
QUESTIONS?
Co-Pay Rebate Form
PP-XEL-USA-5915-01 © 2020 Pfizer Inc. All rights reserved. September 2020
CO-PAY 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. 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 co-pay. After a maximum of
$15,000, 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, co-pay 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. This rebate is not health
insurance. Offer good only in the U.S. and
Puerto Rico. No other purchase is necessary.
Data related to your redemption of the rebate
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 rebate
redemptions and will not identify you. Pfizer
reserves the right to rescind, revoke, or amend
the program without notice. The rebate is
applicable to all XELJANZ formulations.
Rebate and Program expires 12/31/2022.
