Pfizer enCompass™ Co-Pay Assistance

Program for INFLECTRA®:

Guide to Claim Submission and Payment

INFLECTRA is a trademark of Hospira UK, a Pfizer company.

Pfizer enCompass is a trademark of Pfizer.
 Table of Contents
Introduction......................................................................................................................................................................................................................... 3
Submission of Claims to the Pfizer enCompass™ Co-Pay Assistance Program............................................................................................ 4
Submission of INFLECTRA Co-Pay Claims Using Claim Form: Sample Completed Form......................................................................... 5
Submission of INFLECTRA Co-Pay Claims Using Your Office Billing Software............................................................................................ 6
Submission of INFLECTRA Co-Pay Claims Using Claim.MD............................................................................................................................... 7
Registering With EnrollHub to Receive HCP Co-Pay Remittance Through Electronic Funds Transfer (EFT)................................... 11
Specialty Pharmacy Submission of Co-Pay Claims.............................................................................................................................................. 14
Pfizer enCompass Co-Pay Assistance Program for INFLECTRA Specialty Pharmacy Form................................................................... 15

This brochure describes the steps for submission of co-pay claims by healthcare providers (HCPs) to the Pfizer enCompass Co-Pay
Assistance Program for INFLECTRA® (infliximab-dyyb) for Injection and how to register for co-pay remittance via electronic funds
transfer (EFT). The process for a specialty pharmacy to submit co-pay claims is also described in this brochure.

Pfizer enCompass Contact Information

If you have questions about the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA or would like to know more about
patient support available through Pfizer enCompass, please contact a Pfizer enCompass Access Counselor or visit
www.pfizerencompass.com for more information:

1-844-722-6672 1-844-482-4482 Pfizer enCompass www.pfizerencompass.com

Monday–Friday P.O. Box 220040 NOTE: Co-Pay Enrollment Form and
9 am–8 pm ET Charlotte, NC 28222 Claim Form are available on this website
as downloadable, writeable PDFs

Pfizer enCompass Provider Portal

Pfizer enCompass has a secure provider portal at www.pfizerencompassonline.com, for HCPs and their staff. The portal allows the
convenience of online, real-time access to Pfizer enCompass services and resources through electronic submission of requests for a
variety of Pfizer support services, including patient insurance benefit verifications (BVs) and tracking the progress of patient requests.
To get started, select one of the following options:

Visit www.pfizerencompassonline.com and click “Register Now”

Contact your INFLECTRA Field Reimbursement Manager for more information on how to register

Call Pfizer enCompass at 1-844-722-6672 to speak to an Access Counselor about getting started in the Provider Portal

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 Introduction
This guide provides important information to HCPs about the options for co-pay claim submission and receiving co-pay
payments available through the Pfizer enCompass™ Co-Pay Assistance Program for INFLECTRA.
The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA provides eligible commercially insured patients assistance
up to $20,000 per calendar year. Patients now may pay $0 per INFLECTRA treatment for claims received by the program as
of April 1, 2018. The co-pay program covers only drug costs, not procedures, administration fees, or office visits. Please see
full Terms and Conditions below. Physicians, specialty pharmacies (SPs) or patients may submit a co-pay claim to receive
payment. The INFLECTRA co-pay program can provide co-pay assistance under either a medical or pharmacy coverage
benefit. For patients to be eligible for this program, they must have commercial insurance that covers INFLECTRA, and they
cannot be enrolled in a state- or federally funded insurance program.

INFLECTRA Co-Pay Assistance Program Overview

HCP Buys and Bills SP Purchases and Bills

Patient enrolls in/is approved Patient enrolls in/is approved Patient enrolls in/is approved
Enrollment

for co-pay program for co-pay program for co-pay program

Patient does not HCP sends completed Pfizer enCompass

Patient assigns co-pay
assign co-pay benefit Co-Pay Assistance Program SP Form and
benefit to HCP
to HCP INFLECTRA prescription to SP
Submission and

HCP submits co-pay Patient submits co-pay

SP submits co-pay claim
Payment

claim form with EOB claim form with EOB

Claims

HCP receives Patient receives SP receives co-pay payment

co-pay payment co-pay payment

Terms and Conditions

The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA is not valid for prescriptions that are eligible to be reimbursed, in whole or in part,
by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state prescription drug assistance programs) and the
Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”). This program is not health insurance. No
membership fees required.

With this program, eligible patients may be responsible for $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per
calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your
co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. No claim for reimbursement
of the out-of-pocket expense amount covered by this program shall be submitted to any third-party payer, whether public or private. This offer is not
valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or other health or pharmacy benefit
programs. This offer cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription. This offer is limited to
1 per person during this offering period and is not transferable. Offer good only in the United States and Puerto Rico. Certain restrictions may apply.
Offer may not be available to patients in all states. This offer is not valid where prohibited by law, taxed, or restricted. Pfizer reserves the right to
rescind, revoke, or amend this offer without notice. By using this program, you understand and agree to comply with the terms and conditions as set
forth above. For more information about Pfizer, visit www.pfizer.com. For more information about the Pfizer enCompass Co-Pay Assistance Program,
call Pfizer enCompass at 1-844-722-6672, or write to Pfizer enCompass Co-Pay Assistance Program, P.O. Box 220040, Charlotte, NC 28222.

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 Submission of Claims to the Pfizer enCompass™ Co-Pay Assistance Program
When the HCP Purchases and Bills for the Drug (Buy-and-Bill Scenario)

HCP Claims Submission:

HCPs have 3 ways to submit claims to the co-pay assistance program for INFLECTRA:

Buy-and-Bill
1. Fax or mail a Pfizer enCompass Co-Pay Assistance Program Claim Form

2. Utilize your practice’s billing software

3. Utilize Claim.MD
a. Upload claims directly
b. Submit claims manually
c. Submit claims via secure file transfer protocol (sFTP)

For additional information on submitting claims via Claim.MD, refer to the

Submission of INFLECTRA Co-Pay Claims Using Claim.MD instructions on pages 7-10 of
this brochure.

Tip: A sample completed Pfizer enCompass Co-Pay Assistance Program Claim Form is found on page 5. A co-pay
claim form is submitted after the patient is approved and enrolled in the INFLECTRA Co-Pay Assistance Program. The
HCP must submit copies of explanations of benefits (EOBs) for INFLECTRA claims submitted to the patient’s primary
and secondary insurance (if applicable) with the INFLECTRA co-pay claim form.

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 Submission of INFLECTRA Co-Pay Claims Using Claim Form: Sample Completed Form

Pfizer enCompass™ Co-Pay Assistance Program

CLAIM FORM

Claims Submission:
Co-Pay Claim Form
Please fax the completed form to 1-908-809-6240
If you have questions, please call 1-844-722-6672

The Pfizer enCompass Co-Pay Assistance Program for
INFLECTRA® (infliximab-dyyb) for Injection provides
eligible commercially insured patients assistance up to
$20,000 per calendar year for claims received by the
program as of April 1, 2018. Eligible enrolled patients
now may pay $0 for each INFLECTRA treatment. The
co-pay program covers only drug costs, not procedures,
administration fees, or office visits. Please see full Terms
and Conditions below.
If you have questions about the Pfizer enCompass
Co-Pay Assistance Program or if there are any changes
to the patient’s provider, administering provider infusion
provider, insurance, or contact information, please call us at
Patients may be eligible for this offer if they:
• Have commercial insurance that covers INFLECTRA
• Are not enrolled in a state or federally funded insurance program
CLAIMS PROCESS
NOTE: Patients must be enrolled in the Pfizer enCompass Co-Pay Assistance Program.
Please submit the following:
• A completed claim form within 120 days of the issue date on the
patient’s Explanation of Benefits (EOB)
• A copy of the EOB or dated pharmacy receipt if the prescription
was filled by a pharmacy
• The group and member ID information on the Pfizer enCompass
Co-Pay Assistance Program identification card (provided on the
approval letter)

E
1-844-722-6672. Access Counselors are available Submit claims via mail or fax:
Monday–Friday, 9 am–8 pm ET. If there are any updates
Mail: Pfizer enCompass Co-Pay Assistance Program
to the patient’s insurance, please provide it in the noted
area below. P.O. Box 7017, Bedminster, NJ 07921

L
Fax: 1-908-809-6240
Pfizer enCompass Co-Pay Assistance Program | CLAIM FORM
All fields marked with an asterisk (*) are required.

P
ADMINISTERING PROVIDER (Enter the name of the administering provider or infusion center)

Regional Medical Center

PRACTICE NAME

M
Holly Doe, MD
*PROVIDER FIRST NAME *PROVIDER LAST NAME

PATIENT

A
Jane Smith
*PATIENT FIRST NAME *PATIENT LAST NAME PATIENT MIDDLE INITIAL

01234 05/11/1999 05/01/2017 500.00

S
*ZIP CODE *DATE OF BIRTH *DATE OF SERVICE *PATIENT OUT-OF-POCKET
AMOUNT FOR INFLECTRA
EC30005006 01234567891
Male Female
*PATIENT GROUP NUMBER *PATIENT MEMBER ID NUMBER *GENDER
(ie, EX00000000) (from program ID card on the (11-digit ID from program ID card on the approval
approval letter) letter)

UPDATED INSURANCE DETAIL (if the insurance has changed since last submission)

PRIMARY INSURANCE NAME PRIMARY INSURANCE GROUP # FOR PRIMARY INSURANCE GROUP ID FOR
MEDICAL BENEFIT MEDICAL BENEFIT

PRIMARY INSURANCE BIN PRIMARY INSURANCE PCN PRIMARY INSURANCE GROUP # PRIMARY INSURANCE ID
FOR PHARMACY BENEFIT FOR PHARMACY BENEFIT FOR PHARMACY BENEFIT FOR PHARMACY BENEFIT
Terms and Conditions: The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA is not valid for prescriptions that are eligible to be reimbursed, in whole or in
part, by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state prescription drug assistance programs) and the Government Health
Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”). This program is not health insurance. No membership fees required.

With this program, eligible patients may be responsible for $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per calendar year for out-
of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum of
$20,000 you will be responsible for the remaining monthly out-of-pocket costs. No claim for reimbursement of the out-of-pocket expense amount covered by this program
shall be submitted to any third-party payer, whether public or private. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by
your private insurance plans or other health or pharmacy benefit programs. This offer cannot be combined with any other rebate/coupon, free trial or similar offer for the
specified prescription. This offer is limited to 1 per person during this offering period and is not transferable. Offer good only in the United States and Puerto Rico. Certain
restrictions may apply. Offer may not be available to patients in all states. This offer is not valid where prohibited by law, taxed, or restricted. Pfizer reserves the right to
rescind, revoke, or amend this offer without notice. By using this program, you understand and agree to comply with the terms and conditions as set forth above. For more
information about Pfizer, visit www.pfizer.com. For more information about the Pfizer enCompass Co-Pay Assistance Program, call Pfizer enCompass at 1-844-722-6672,
or write to Pfizer enCompass Co-Pay Assistance Program, P.O. Box 220040, Charlotte, NC 28222.

PEN-IFA-20180226-026 © 2018 Pfizer Inc. All rights reserved. Printed in USA/March 2018

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 Submission of INFLECTRA Co-Pay Claims Electronically Using Your Office Billing
Software

1. Within your billing software, search for PSKW0 (PSKW zero) as an available payer.

If PSKW0 is an available payer,
you may begin submitting
electronic claims transactions
(837 files)
Claims Submission:
Billing Software
If PSKW0 is not available, please
work directly with your software
vendor to add PSKW0 as an
available payer

After confirming that PSKW0 is an available payer within your software,

please add the INFLECTRA Co-Pay Program to your patient’s insurance
profile as a secondary payer. Make sure to include the payer ID (PSKW0),
group number (EC30005006), and program member ID. Claims
submitted without this information will be rejected automatically

2. Request that your practice management software vendor accept electronic remittance advice (ERA) (835)
transactions from PSKW0.

After this request is fulfilled by your vendor, you should receive an ERA
approximately 5 to 7 business days after claim submission

Additional information on submission of co-pay claims electronically through Claim.MD

is found on pages 7-10 of this brochure.

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 Submission of INFLECTRA Co-Pay Claims Using Claim.MD

The co-pay payer for the INFLECTRA Co-Pay Program has an established relationship with Claim.MD.
HCPs can submit INFLECTRA co-pay claims through Claim.MD by completing the following steps:

Claims Submission:
Claim.MD
1. Register and complete account setup with Claim.MD. Your IT and EDI Coordinator may be able to help.
2. Once registered, INFLECTRA co-pay claims can be submitted by one of the following methods:
a. Upload claims directly
b. Upload claims manually
c. Submit claims via sFTP

Details on each of the above methods for use of Claim.MD to submit INFLECTRA
co-pay claims are found on pages 8-10 of this brochure.

Some co-pay payers have established relationships with leading software vendors and clearinghouses, such as
the entities listed below. If a specific entity is not listed, please contact Pfizer enCompass™ at 1-844-722-6672 for
assistance.
• Change Healthcare • ABILITY Network • NaviCure
• Claim.MD • Infinedi • Office Ally
• ClaimLogic/TriZetto • Capario • Passport Health
• Availity • eClaims • RealMed

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 **Attention EDI Coordinator**
Using Claim.MD to Upload Claims Directly

Please ask the person in your office who manages EDI enrollment to complete the following steps to register
and get started:

Navigate to the registration site at claim.md/crx/

1. Complete the required personal information to begin the registration
• You will receive an activation email. Click the link within the email to continue the registration process
2. Complete your account setup
• Provide your practice name and contact details
• Select your billing system. If your billing system is not listed, choose “Other”
• Select “Full Access” in the vendor access field on the vendor settings page
• Review and agree to the Business Associate Agreement
• Provide practice details
3. Complete the claims-mapping process
• Select “Upload Claims” from the claim menu
• Select the claim to be uploaded and click “Upload Selected File”
• Within 3 to 5 business days, you will receive an email notification that you may begin uploading claims

Once complete, you will receive a confirmation email from Claim.MD that will include your username and account ID.

Follow these steps to begin uploading claim files within the web interface:
1. Create a claim file within your billing system
• Refer to your individual billing system instructions on how to do this
2. Navigate to Claim.MD website at claim.md/crx/
3. Log in to your account
4. Upload claims
• Select “Upload Claims” from the claim menu
• Select the claim to be uploaded and click “Upload Selected File”
5. Transmit the claim
• Select “Manage Claims” from the claim menu
• Select “Approve Transmit”

Once a claim is submitted, you should receive an ERA within the Claim.MD interface within approximately 5 to 7 business
days.

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 Using Claim.MD to Upload Claims Manually
Please ask the person in your office who manages EDI enrollment to complete the following steps to register
and get started:

Navigate to the registration site at claim.md/crx/

1. Complete the required personal information to begin the registration
• You will receive an activation email. Click the link within the email to continue the registration process
2. Complete your account setup
• Provide your practice name and contact details
• Select your billing system. If your billing system is not listed, choose “Other”
• Select “Full Access” in the vendor access field on the vendor settings page
• Review and agree to the Business Associate Agreement
• Provide practice details

Once complete, you will receive a confirmation email from Claim.MD that will include your username and account ID.

Follow these steps to begin uploading claims:

Navigate to the Claim.MD website at claim.md/crx/

1. Log in to your account
2. Enter a claim
• Select “Manage Claims” from the claim menu
• Select “Create Blank Claim”
• Complete claim data entry
— To ensure accurate transmission, make sure that “PSKW0” is selected as a secondary payer
• Save the claim
3. Transmit the claim
• Select “Manage Claims” from the claim menu
• Select “Approve Transmit”

Once a claim is submitted, you should receive an ERA within the Claim.MD interface within approximately 5 to 7 business
days.

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 Using Claim.MD to Submit Claims via sFTP

Please ask the person in your office who manages EDI enrollment to complete the following steps to register
and get started:

Navigate to the registration site at claim.md/crx/

1. Complete the required personal information to begin the registration
• You will receive an activation email. Click the link within the email to continue the registration process
2. Complete your account setup
• Provide your practice name and contact details
• Select your billing system. If your billing system is not listed, choose “Other”
• Select “Full Access” in the vendor access field on the vendor settings page
• Review and agree to the Business Associate Agreement
• Provide practice details

Once complete, you will receive a confirmation email from Claim.MD that will include your username and account ID.

Follow these steps to begin uploading claims:

Navigate to Claim.MD website at claim.md/crx/

1. Log in to your account
2. Select “Manage Users”
3. Select “sFTP”
• Provide your contact details
• Click “New” to submit your request

Once complete, you will receive an email confirming your access and sFTP site information.

Follow these steps to set up sFTP access:

1. Connect to the sFTP folder using your office’s established process
• The sFTP site address and port information will be provided in your confirmation email from Claim.MD
2. Submit the claim
• Select the claim file
• Move the claim to the upload folder (/SendFiles)

Please allow 5 to 7 business days for processing. You will return to the sFTP site and retrieve the ERA from the download
folder (/ReceiveFiles).

There are many ways to access the sFTP site. Please contact your facility’s technical support if you are unsure about
your office’s process.

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 Registering With EnrollHub to Receive HCP Co-Pay Remittance Through EFT

If a patient has checked “Yes” to the assignment of benefits (AOB) statement in Section 7 of the Pfizer enCompass™
Enrollment Form to authorize co-pay payment directly to the HCP, HCPs may elect to submit the co-pay claim form

Payment Process
HCP Electronic
and receive co-pay remittance for their patients as a paper check or through EFT. To receive payment through EFT,
HCPs should register in advance of submitting the first claim to avoid payment delays. HCPs can enroll in EFT on the
EnrollHub website at https://solutions.CAQH.org.

See the How to Register With EnrollHub to Receive EFT Payments for the Pfizer enCompass Co-Pay
Assistance Program instructions on pages 12-13 for more information.

• Once registered for EFT payment, the HCP will submit the co-pay claim and the EOB from the patient’s
primary and/or secondary insurance (if applicable) for INFLECTRA
• When the co-pay claim is approved, the HCP will receive an email notifying them that payment has been
sent for a specific patient (see sample email on page 13)
• Each EFT transaction in the HCP bank statement for the Pfizer enCompass Co-Pay Assistance Program
will be denoted as “Pfizer enCompass,” and each patient’s co-pay payment will be listed separately. Each
bank may present EFT payments to its account holders differently. The HCP bank statement may include
additional co-pay assistance program information, such as the patient co-pay program Member ID Number

If you have any questions about your EFT transactions in your bank statement,
please call Pfizer enCompass at 1-844-722-6672.

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 How to Register With EnrollHub to Receive EFT Payments for the Pfizer enCompass™
Co-Pay Assistance Programa

Please have the following information available:

New • Practice name, address, phone, and fax
• Tax identification number
EnrollHub Users • Bank account information
• An image of a check or a bank letter

Follow these steps to register and enroll in EFT:

1. Navigate to the EnrollHub website at https://solutions.caqh.org
2. Click the “Register Now” button
• Complete the required personal information
• Create a username and password
• Set up security questions
3. Activate your account and log in
• You will receive an activation email. Click the link within the email to log in and complete the registration
process
4. Create a provider record by providing practice details and banking information and uploading the check image or
bank letter
5. Enroll in EFT by selecting your bank account and selecting ConnectiveRx from the payer list
• Accept the payment terms agreement

Please have the following information available:

Existing • Username
EnrollHub Users • Login

Follow these steps to register and enroll for EFT:

1. Navigate to the EnrollHub website at https://solutions.caqh.org
2. Log in to your account
3. Enroll in EFT by selecting your bank account and selecting ConnectiveRx from the payer list
• Accept the payment terms agreement
• Complete your submission by clicking “Confirm”

a
ConnectiveRx administers the Pfizer enCompass Co-Pay Assistance Program. ConnectiveRx partners with industry leading EnrollHub to
support the collection of your EFT enrollment information.

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 EFT Payment Next Steps
• EnrollHub will verify your account information by submitting a payment to you in the amount of $.01
• Your bank will receive the payment, verify account information, and either accept or reject the paymentb
• You will receive an email from EnrollHub notifying you of the outcome of the account verification process
• If rejected, please follow instructions within the email to review the account information and resubmit
• Once your account has been approved, EnrollHub will share your enrollment with the Pfizer enCompass™ Co-Pay
Assistance Program for INFLECTRA, so no separate registration with Pfizer enCompass is required. You are able to
receive EFT payments for co-pay claims submitted through the Pfizer enCompass Co-Pay Assistance Program for
INFLECTRA within 2 to 3 weeks of enrollment. In the interim, all eligible claims will be paid by check

b
It may take up to 10 business days for your bank to complete this transaction.

If you need more information or account support, you may access the EnrollHub Getting Started document
at https://solutions.caqh.org/bpas/Common/HelpGettingStarted.pdf.

Pfizer enCompass Co-Pay HCP EFT Notification of Funds Transfer Email

To: <Billing Email Address>

From: donotreply-PfizerenCompass@Pskw.net Pfizer enCompass™ Co-Pay Assistance
Program
Subject: Pfizer enCompass™ Co-Pay Assistance Program Electronic Funds Transfer
____________________________________________________________________________

Dear <Billing Contact Name>,

Thank you for your participation in the Pfizer enCompass™ Co-Pay Assistance Program for
INFLECTRA® (infliximab-dyyb) for Injection. This notification is to inform you that funds have
been transferred to your account in the amount of <$$$.$$> on behalf of <Patient First name>
<Patient Last name>, <Patient DOB>, covering the out-of-pocket costs for the treatment
administered on <Date of Service>. This amount reflects the patient’s out-of-pocket costs
incurred and covered by the program. Please see full Terms and Conditions below.

Please do not reply to this email. This email address does not accept incoming messages. If
you have questions about the Pfizer enCompass Co-Pay Assistance Program, or if there are
any changes to the provider, administering provider, insurance coverage, or contact information,
please call us at 1-844-722-6672. We are available Monday–Friday, 9 AM–8 PM ET.

Sincerely,
Pfizer enCompass Co-Pay Assistance Program for INFLECTRA

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 Processing Pfizer enCompass™ Co-Pay Assistance Program Claims
When an SP Dispenses INFLECTRA and Bills the Patient’s Insurance Plan
In certain cases, the HCP may send the prescription to an SP (eg, when INFLECTRA is covered under the patient’s

Specialty Pharmacy
Claims Submission
prescription benefits or when a patient’s commercial insurance requires INFLECTRA to be obtained through a payer-
affiliated SP).

• The HCP or patient provides patient co-pay information to the specialty pharmacy to
process co-pay claims. The HCP completes and sends, with the prescription, the Pfizer
enCompass Co-Pay Assistance Program for INFLECTRA Specialty Pharmacy Form
(see blank form for HCP use on next page of this resource)

OR

• Your patient may also provide the co-pay claims-processing information on their Pfizer
enCompass Co-Pay Program ID Card directly to the pharmacist

• The pharmacy processes the co-pay claim and collects any additional balance due from
the patient

When an SP purchases and bills for INFLECTRA, the HCP is not responsible for billing the
patient’s primary insurance plan or the co-pay assistance program for INFLECTRA

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 Pfizer enCompass™ Co-Pay Assistance Program
for INFLECTRA® (infliximab-dyyb) for Injection Specialty Pharmacy Form
PLEASE NOTE:
This fax form can be used by a patient's HCP to provide important information to a specialty pharmacy for a patient who has been approved and
enrolled in the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA when a patient's INFLECTRA co-pay claim needs to be processed by
the specialty pharmacy.

When sending/faxing this form to a specialty pharmacy, please send/attach the prescription for INFLECTRA.

TO: FAX #:
(Pharmacy Name) (Pharmacy Fax)

FROM: DATE: TOTAL PAGES:

(Practice Name)

PATIENT NAME: DATE OF BIRTH:

The patient noted above has been approved to participate in the Pfizer enCompass Co-Pay Assistance Program
for INFLECTRA.

The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA provides eligible commercially insured patients
assistance up to $20,000 per calendar year. Patients now may pay $0 per INFLECTRA treatment for claims received
by the program as of April 1, 2018. The co-pay program covers only drug costs, not procedures, administration fees or
office visits. Please see full Terms and Conditions below.

Specialty pharmacies should utilize the following information from the patient's Pfizer enCompass Co-Pay
Assistance Program identification card when submitting claims to the INFLECTRA co-pay assistance program:

BIN #: 004682 PCN #: CN

ID #: GROUP #: EC30005006
Patient Member Number
(Use 11-digit Patient Member ID Number from the Pfizer enCompass Co-Pay Assistance Program identification card sent with the patient's approval letter)

Pharmacist instructions for a patient with an Authorized Third-Party Payer: Submit the claim to the primary third-party
payer first, then submit the balance due for the co-pay or coinsurance, and secondary claim (if applicable) to Therapy First
Plus as a secondary payer coordination of benefits (COB) with patient responsibility amount and a valid Other Coverage Code
(eg, 8). The patient now may pay $0 per INFLECTRA treatment. The offer pays up to $20,000 per year. You will receive
reimbursement from Therapy First Plus. For any questions regarding Therapy First Plus online processing, please call the
Help Desk at 1-800-422-5604.

If you have any questions about processing a patient's INFLECTRA co-pay claim through a pharmacy benefit or the Pfizer enCompass
Co-Pay Assistance Program, please call 1-844-722-6672 and speak to an Access Counselor. Representatives are available
Monday–Friday, 9 AM–8 PM ET.

Terms and Conditions: The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA is not valid for prescriptions that are eligible to
be reimbursed, in whole or in part, by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state
prescription drug assistance programs) and the Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma
de Salud”). This program is not health insurance. No membership fees required.

With this program, eligible patients may be responsible for $0 co-pay per INFLECTRA treatment, subject to a maximum benefit of $20,000 per
calendar year for out-of-pocket expenses for INFLECTRA including co-pays or coinsurances. The amount of any benefit is the difference
between your co-pay and $0. After the maximum of $20,000 you will be responsible for the remaining monthly out-of-pocket costs. No claim
for reimbursement of the out-of-pocket expense amount covered by this program shall be submitted to any third-party payer, whether public or
private. This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plans or
other health or pharmacy benefit programs. This offer cannot be combined with any other rebate/coupon, free trial or similar offer for the
specified prescription. This offer is limited to 1 per person during this offering period and is not transferable. Offer good only in the United
States and Puerto Rico. Certain restrictions may apply. Offer may not be available to patients in all states. This offer is not valid where
prohibited by law, taxed, or restricted. Pfizer reserves the right to rescind, revoke, or amend this offer without notice. By using this program,
you understand and agree to comply with the terms and conditions as set forth above. For more information about Pfizer, visit
www.pfizer.com. For more information about the Pfizer enCompass Co-Pay Assistance Program, call Pfizer enCompass at 1-844-722-6672,
or write to Pfizer enCompass Co-Pay Assistance Program, P.O. Box 220040, Charlotte, NC 28222.

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