Oxbryta Commerical Copay Program Terms And Conditions

By using the Oxbryta Commercial Copay Program Copay Card* (the “eCard”), you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

• Minimum Eligibility Criteria:
  • U.S. Resident (or a resident of a U.S. territory)
  • Have a valid prescription for an on-label diagnosis from a healthcare professional licensed in the U.S. or a U.S. territory
  • 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
• The value of this eCard is limited to the amount of your copay per use, up to a maximum of $15,000 per calendar year. The calendar year is defined by the date of enrollment through December 31st of the enrollment year. After the $15,000 maximum annual benefit is reached, you will be responsible for the remaining monthly out-of-pocket costs
• This eCard 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 eCard 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 eCard 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 eCard if your insurer or health plan prohibits use of manufacturer eCards
• This eCard is not valid where prohibited by law
• The benefit under the copay card program is offered to, and 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, pharmacy benefit managers, or the agents of either
• This eCard cannot be combined with any other external savings, free trial or similar offer for the specified prescription (including any program offered by a third-party payer or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations, through arrangements that may be referred to as “accumulator” or “maximizer” programs)
• Third-party payers, pharmacy benefit managers, or the agents of either, are prohibited from assisting patients with enrolling in the copay card program
• This eCard will be accepted only at participating pharmacies
• This eCard is not health insurance
• Offer good only in the U.S. and Puerto Rico
• This eCard is limited to 1 per person during this offering period and is not transferable
• This eCard may not be redeemed more than once per 30 days per patient
• No other purchase is necessary
• Data related to your redemption of the eCard 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 eCard redemptions and will not identify you
• Pfizer reserves the right to rescind, revoke or amend this offer without notice
• Offer expires: 12/31/2024

• The program terms and conditions apply regardless of whether the eligible patient receives an electronic copay savings card or an electronic combined copay savings card/debit card.

If you have questions or are in need of additional support, call 1-833-428-4968 or visit www.YourSourceSupport.com.