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Terms and Conditions By enrolling in the 30-day trial program for BOSULIF® (bosutinib), you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below. • The patient, or healthcare provider on the patient’s behalf, must provide a valid prescription to the BOSULIF 30-day free trial offer. • The program is valid for one 30-day trial. Trial cannot exceed 30 days. • The patient, or the healthcare provider on the patient’s behalf, must not submit any claim for reimbursement for product dispensed pursuant to this program to any third party payor, including Medicare, Medicaid, or any other federal or state health care program. The patient must not apply the value of the free product received through this program toward any government insurance benefit out-of-pocket spending calculations, such as Medicare Part D True Out-of-Pocket Costs (TrOOP). • Patients who have already begun therapy with BOSULIF are not eligible to participate in the program. • Patients must be at least eighteen (18) years of age to be eligible to participate in the program. • Only 1 program enrollment per person per lifetime. • Massachusetts residents whose prescriptions are covered in whole or in part by third party insurance are not eligible for this program. • Program not available where prohibited by law. • This free trial is not health insurance. • This program cannot be combined with any other savings, free trial, or similar offer for the specified prescription. • Offer good only in the United States and Puerto Rico. • Pfizer reserves the right to rescind, revoke, or amend this free trial program without notice. • This free trial program expires 03/31/2020. To order a free trial offer: 1. Attach the voucher to a new 30-day prescription for BOSULIF. 2. Fax the voucher and prescription to 1-855-578-1686—do not submit to a pharmacy. Please include patient’s personal information (name, address, phone number, and date of birth), along with physician’s information (name, office address, phone number, and signature). 3. The 30-day supply of BOSULIF will be shipped directly to the patient once the request is approved and processed. To continue the patient on BOSULIF: 4. Write a separate prescription to be filled at an in-network specialty pharmacy. Please consider the time needed for coverage verification when writing the second prescription. The list of specialty pharmacies can be found on the Forms & Resources page at PfizerOncologyTogether.com/hcp EXPIRATION DATE: 3/31/2020. PP-BOS-USA-0534-02 400-, 500-, or 100-mg 1-MONTH (30-DAY) TRIAL VOUCHER For your patients initiating therapy 1 month (30 days) free trial offer of BOSULIF® (bosutinib)* If you have any questions about the voucher program, please call 1-855-541-5929; for additional vouchers, contact your Pfizer Account Specialist. *Limits, terms, and conditions apply. Please see full list of terms and conditions at right. PP-BOS-USA-0534-01 © 2019 Pfizer Inc. All rights reserved. January 2019 Only new patients may use this voucher. By redeeming this voucher, you certify that you are not currently using BOSULIF. Only 1 voucher per person may be redeemed under this program. This voucher is not transferable. An original voucher and a valid prescription must be presented. This voucher is only valid with the program administrator—it cannot be redeemed at a pharmacy. No claim for reimbursement for product dispensed pursuant to this voucher may be submitted to any third-party payor, whether private or government payor. This free trial voucher is not valid where prohibited by law. This free trial is not health insurance. Offer good only in U.S. and Puerto Rico. Pfizer reserves the right to rescind, revoke, or amend this free trial voucher without notice. This free trial voucher expires 3/31/2020. For a commercially insured patient with co-insurance requirements without a maximum out-of-pocket limit, savings could be greater and depend on the benefit design.
