Full Terms and Conditions

VELSIPITY (etrasimod) Copay Savings Program Terms and Conditions

By participating in the VELSIPITY Copay Savings Program and using the VELSIPITY Copay Savings Card (the “Program”), 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 Program 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 who move from private insurance to the above-mentioned state or federal healthcare insurance programs will no longer be eligible.
Offer is only available to patients who have been diagnosed with an FDA-approved indication for VELSIPITY (etrasimod).
The value of the prescription offer is limited to the amount of your copay. Patients may pay as little as $0 in out-of-pocket costs per prescription, subject to a maximum benefit of $16,000 during a calendar year.
The value of the offer for reimbursement of qualified out-of-pocket expenses is a one-time reimbursement amount of up to $2,500, which include baseline assessments/prescreening tests for the initial blood tests, ECG screening, eye exam, and baseline skin examination where the full cost is not covered by patient's insurance. This offer only applies to the above-mentioned qualified expenses and is not eligible for patients residing in Minnesota or Rhode Island.
To receive reimbursement for qualified out-of-pocket expenses, an Explanation of Benefits (EOB) form must be submitted, along with copies of receipts for any payments made. After the $2,500 maximum is reached, you will be responsible for paying the remaining monthly out-of-pocket costs.
Patient must be 18 years of age or older.
This Program is not valid when the entire cost of your prescription drug and/or qualified out-of-pocket expense are eligible to be reimbursed by your private insurance plan or other private health or pharmacy benefit programs.
You must deduct the value of this 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 Card to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription and/or qualified out-of-pocket expenses filled using this Program, as may be required.
You should not use this Program if your insurer or health plan prohibits use of manufacturer Cards.
The program is not valid where prohibited by law.
This program cannot be combined with any other savings, free trial, or similar offer for the specified prescription.
The prescription offer of the Copay Savings Program will be accepted only at participating pharmacies.
If your pharmacy does not participate, you may be able to submit a request for a rebate of the cost for the prescription in connection with this offer. The rebate form can be found at www.VELSIPITY.com.
The Copay Savings Program is not health insurance.
Offer good only in the U.S. and Puerto Rico. The Card is limited to 1 per person during this offering period and is not transferable.
The Card may not be redeemed more than once per 30 days per patient.
No other purchase is necessary.
Data related to your redemption of the Card may be collected, analyzed, and shared with Pfizer, for market research and other purposes related to assessing Pfizer’s programs.
Pfizer reserves the right to rescind, revoke, or amend the Program without notice.
Program expires 12/31/2024.
If you have questions or are in need of additional support, call 800-350-3080, visit www.VELSIPITY.com or mail VelsipityForMe at 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067.

VELSIPITY At-Home Baseline Assessment/Prescreening Tests Program Terms and Conditions

By agreeing to participate in the VELSIPITY At-Home Baseline Assessment/Prescreening Tests Program, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

Patients are not eligible for the VELSIPITY At-Home Baseline Assessment/Prescreening Tests Program if they are enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or if they reside in Massachusetts, Michigan, Minnesota, or Rhode Island.
The VELSIPITY At-Home Baseline Assessment/Prescreening Tests Program is valid only for patients with (private) insurance. Baseline Assessments/Prescreening Tests include initial blood tests, an ECG screening, an eye exam, and a baseline skin examination where the full cost is not covered by patient’s insurance.
Offer is only available to patients who have been diagnosed with an FDA-approved indication for VELSIPITY (etrasimod).
Patient must be 18 years of age or older.
The VELSIPITY At-Home Baseline Assessment/Prescreening Tests Program is not health insurance.
Patients must be enrolled in the VelsipityForMe program and eligibility must be verified prior to participating in the VELSIPITY At-Home Baseline Assessment/Prescreening Tests Program.
Offer only good in the U.S. and Puerto Rico.
No other purchase is necessary.
The program is not valid where prohibited by law.
Other patient support services offered through VelsipityForMe cannot begin until a signed Baseline Assessment Confirmation form is received by VelsipityForMe by the prescribing health care provider.
Pfizer reserves the right to rescind, revoke, or amend the program without notice.
If you have questions or are in need of additional support, call 800-350-3080 or visit www.VELSIPITY.com or mail VelsipityForMe at 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067.

VELSIPITY ECG INTERPRETATION TERMS AND CONDITIONS

By agreeing to participate in the VELSIPITY ECG Interpretation Program, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

Patients are not eligible for the VELSIPITY ECG Interpretation Program if they are enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or if they reside in Massachusetts, Michigan, Minnesota, or Rhode Island.
The VELSIPITY ECG Interpretation Program is valid only for patients with commercial (private) insurance.
Offer is only available to patients who have been diagnosed with an FDA-approved indication for VELSIPITY (etrasimod).
The VELSIPITY ECG Interpretation Program is only available to patients if an ECG has been previously conducted within 6 months of the request for service.
The VELSIPITY ECG Interpretation Program is not health insurance.
Patients must be enrolled in the VelsipityForMe program to participate in the VELSIPITY ECG Interpretation Program.
Offer only good in the U.S. and Puerto Rico.
No other purchase is necessary.
The program is not valid where prohibited by law.
Patient must be 18 years of age or older.
Other patient support services offered through VelsipityForMe cannot begin until a signed Baseline Assessment Confirmation form is received by VelsipityForMe by the prescribing health care provider.
Pfizer reserves the right to rescind, revoke, or amend the program without notice.
If you have questions or are in need of additional support, call 800-350-3080, visit www.VELSIPITY.com or mail VelsipityForMe at 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067.

COPAY 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”).
Offer is only available to patients who have been diagnosed with an FDA-approved indication for VELSIPITY (etrasimod).
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.
The value of the prescription offer is limited to the amount of your copay. Patients may receive up to a maximum benefit of $16,000 per calendar year, which is defined by the date of enrollment through December 31st of the enrollment year.
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, copay 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.
Rebate and Program expire 12/31/2024.
If you have questions or are in need of additional support, call 800-350-3080 or visit www.VELSIPITY.com, or mail VelsipityForMe at 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067.

INTERIM CARE RX PROGRAM TERMS AND CONDITIONS

Interim Care Rx is not health insurance and is available for eligible, commercially insured patients who experience a delay or denial in insurance coverage during the prior authorization or appeal process or denial due to a new market block. Offer is only available to patients who have been diagnosed with an FDA-approved indication for VELSIPITY. No claim for reimbursement for product dispensed pursuant to this offer may be submitted to any third-party payer. Not available to patients covered under Medicaid, Medicare, or other federal or state healthcare programs, including any state prescription drug assistance programs and the Government Health Insurance Plan or for residents of Massachusetts, Michigan, Minnesota, or Rhode Island. Available up to a 30-day supply. Refills are subject to limitations. To be eligible for an additional 30-day refill, the patient must be actively pursuing coverage through their insurance awaiting a prior authorization/appeal decision or removal of a new to market block. For patients awaiting removal of a new to market block from their insurance provider, VELSIPITY may be provided for up to 180 days. Interim Care for VELSIPITY may not exceed 2 years for any patient. Interim Care Rx offer does not require, nor will be made contingent on, purchase requirements of any kind. Pfizer reserves the right to amend, rescind, or discontinue this program at any time without notification. Interim Care Rx can only be dispensed by the exclusive pharmacy and only after benefits investigation has been completed and a delay occurs in the prior authorization or appeals process. Offer good only in the U.S. and Puerto Rico. Prescription must be provided by a healthcare provider licensed in the U.S. or Puerto Rico. Continued eligibility for the program requires submission of two appeals within 180 days of enrollment. After 12 months of program enrollment, an updated prescription and benefits investigation is required to confirm continued eligibility. Additional eligibility criteria may apply. If you have questions or are in need of additional support, call 800-350-3080 or visit www.VELSIPITY.com., or mail VelsipityForMe at 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067.

VOUCHER PROGRAM TERMS AND CONDITIONS

You will receive a one-time 30-day supply of VELSIPITY.
Only new patients may use this voucher and each patient is limited to one voucher. By redeeming this voucher, you certify that you are not currently using VELSIPITY.
This voucher may not be transferred, sold, purchased, traded, or counterfeited.
An original voucher and a valid prescription must be presented to the pharmacy.
The voucher will be accepted only at participating pharmacies.
You must not submit any claim for reimbursement for product dispensed pursuant to this voucher to any third party payor, including Medicare, Medicaid, or any other federal or state health care program. You cannot apply the value of the free product received through this voucher toward any government insurance benefit out-of-pocket spending calculations, such as Medicare Part D True Out-of-Pocket Costs (TrOOP).
You must be 18 years of age or older to redeem this voucher.
This voucher is not valid for Massachusetts residents whose prescriptions are covered in whole or in part by third party insurance.
This voucher is not valid where prohibited by law.
This voucher cannot be combined with any other external savings, free trial or similar offer for the specified prescription. This voucher should not be combined with samples for the specified prescription.
This free trial voucher is not health insurance.
This free trial voucher may not be used to address delays or gaps in health insurance coverage for the specified prescription.
Offer good only in the U.S. and Puerto Rico.
No purchase is necessary.
Patients have no obligation to continue to use VELSIPITY.
Pfizer reserves the right to rescind, revoke or amend this offer without notice.
This voucher expires 12/31/2024.

COMBINED COPAY SAVINGS PROGRAM ABBREVIATED TERMS AND CONDITIONS

Only applied when both offers are presented together in messaging

Eligibility required. Commercially insured patients only. The maximum annual prescription offer per patient is $16,000 per calendar year. The value of the offer for reimbursement of qualified out-of-pocket expenses for certain baseline assessment/prescreening tests is a one-time reimbursement amount of up to $2,500 where the full cost is not covered by patient's insurance. Patients enrolled in a state or federally funded prescription health insurance program or who are residents ofMN or RI are not eligible for the medical benefit. No membership fees. This is not health insurance. Available only to patients who have been diagnosed with an FDA-approved indication for VELSIPITY.

Digital pieces

Terms and conditions apply. Visit www.VELSIPITY.com for full Terms and Conditions

COPAY SAVINGS PROGRAM ABBREVIATED TERMS AND CONDITIONS

Only applied when speaking about Copay Savings Program

Eligibility required. Commerciallyinsured patients only. The maximum prescription benefit offer per patient is$16,000 per calendar year. Patients enrolled in a state or federally fundedprescription health insurance program are not eligible. No membership fees.This is not health insurance. Available only to patients who have beendiagnosed with an FDA-approved indication for VELSIPITY.

Digital pieces

Terms and conditions apply. Visit www.VELSIPITY.com for full Terms and Conditions

VELSIPITY AT-HOME BASELINE ASSESSMENT/PRESCREENING TESTS PROGRAM ABBREVIATED TERMS AND CONDITIONS

Eligibility required. At-home baseline assessment services are not available for patients enrolled in a state or federally funded health insurance program, or patients who reside in MA, MI, MN, or RI.

Note: If content does not include “Eligible, commercially insured patients” then add“Commercially insured patients only.” after “Eligibility required.”

Digital pieces

Terms and conditions apply. Visit www.VELSIPITY.com for full Terms and Conditions

VELSIPITY ECG INTERPRETATION ABBREVIATED TERMS AND CONDITIONS

Eligibility required. Not available for patients enrolled in a state or federally funded health insurance program, or patients who reside in MA, MI, MN, or RI. The VELSIPITY ECG Interpretation Program is only available to patients if an ECG has been previously conducted within 6 months of the request for service.

Note: If content does not include “Eligible, commercially insured patients” then add“Commercially insured patients only.” after “Eligibility required.”

Digital pieces

Visit www.VELSIPITY.com for full Terms and Conditions.

INTERIM CARE Rx PROGRAM ABBREVIATED TERMS AND CONDITIONS

Digital pieces

Visit www.VELSIPITY.com for full Terms and Conditions.

OOP REIMBURSEMENT (MEDICAL BENEFIT)

For materials that do not include mention of ECG in regard to the OOP reimbursement

Eligibility required. Commercially insured patients only. The value of the offer is a one-time reimbursement amount of up to $2,500 where the full cost is not covered by patient's insurance. Patients enrolled in a state or federally funded prescription health insurance program or who are residents of MN or RI are not eligible for the medical benefit. Available only to patients who have been diagnosed with an FDA-approved indication for VELSIPITY. No membership fees. This is not health insurance.

Formaterials that include mention of ECG in regard to the OOP reimbursement

Eligibilityrequired. Commercially insured patients only. The baseline assessments medicalbenefit offer is subject to a maximum one-time benefit of $2,500 for qualifiedout-of-pocket expenses and includes initial blood tests, ECG screening, eyeexam, and baseline skin examination where the full cost is not covered bypatient's insurance. Patients enrolled in a state or federally fundedprescription health insurance program or who are residents of MN or RI are noteligible for the medical benefit. Available only to patients who have beendiagnosed with an FDA-approved indication for VELSIPITY. No membership fees. This is not health insurance.