Pay as low as $4 per month for each fill of
brand-name PROTONIX (pantoprazole sodium)*
This temporary card is activated and can be used to start saving right away!
Take your prescription for brand-name PROTONIX and PROTONIX Savings Card
Ask for brand-name PROTONIX. 3.
Keep your card and use it to save on future PROTONIX prescriptions. Please note a permanent card should arrive by mail in 3 to 4 weeks. When you receive it, it will already be activated.
*Terms and Conditions
By participating in the PROTONIX Savings Card Program, you acknowledge that you currently meet the eligibility criteria and will
comply with the terms and conditions described below:
• The Card is not
valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, 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”)
• The Card is not
valid for prescriptions that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs
which reimburse you for the entire cost of your prescription drugs
• Patients must be 18 or older• You must deduct the savings received under this program from any reimbursement request submitted to your insurance plan, either directly by you
• Eligible patients will pay a minimum of $4 per prescription fill. By using the Card, eligible patients will receive a savings of up to $70 per fill off of their
co-pay or out-of-pocket costs. The Card is good for a maximum savings of $840 per year ($70 per month x 12 months). The Card limits your prescription
cost to $4, subject to a $70 maximum monthly benefit. Thus, if your co-pay or out-of-pocket cost is more than $74, you will save $70 off of your co-pay
or total out-of-pocket costs. [Example: If your co-pay or out-of-pocket costs are $100, you will pay $30 ($100-$70 = $30).] If your co-pay or out-of-
pocket costs are no more than $74, you pay $4. For a mail-order 3-month prescription, your total maximum savings will be $210 ($70 x 3)
• The Card is not valid for Massachusetts residents whose prescriptions are covered, in whole or in part, by third-party insurance, or where otherwise
• The Card cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription• The Card will be accepted only at participating pharmacies
• The Card is not health insurance
• This offer is good only in the U.S. and Puerto Rico
• The Card is limited to one per person during this offering period and is not transferable
• Pfizer reserves the right to rescind, revoke, or amend the program without notice• No membership fees.
The Card and Program expire on 12/31/15
Visit PROTONIX.com for more information about PROTONIX. For help with the PROTONIX Savings Card Program, call 1-855-807-7901, or write:
PROTONIX Savings Card Program, Pfizer Inc, c/o PSKW, PO BOX 7017, Bedminster, NJ 07921.
If your pharmacy does not accept the PROTONIX Savings Card, or if you are redeeming your prescription by mail, simply pay your PROTONIX prescription
as you normally would. Then, make a photocopy of the front of your PROTONIX Savings Card as well as the original pharmacy receipt (cash register
receipt NOT valid) with product name, date, and amount circled, and mail them both to: PROTONIX Savings Card Program, Pfizer Inc, c/o PSKW, PO BOX
7017, Bedminster, NJ 07921-7017. Be sure to include your name and mailing address, and a check will be mailed to you within 3 weeks.
• For a patient with an Eligible Third Party
, submit the claim to the primary Third Party Payer first, then submit the balance due to Therapy First
as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8)
. The patient
is responsible for the first $4 and the card pays up to the next $70. Reimbursement will be received from Therapy First Plus
• For a cash paying patient
, submit this claim to Therapy First Plus
. A valid Other Coverage Code (e.g. 1)
is required. The patient is responsible
for the first $4 and the card pays up to the next $70. Reimbursement will be received from Therapy First Plus
• Valid Other Coverage Code required. For any questions regarding Therapy First Plus
online processing, please call the Help Desk at 1-800-422-5604
TO PATIENTS AND PHARMACISTS:
For help processing the card, call 1-855-807-7901
Please see full Prescribing Information and Medication Guide at www.PROTONIX.com.
PSE602902-02 2013 Pfizer Inc. All rights reserved. September 2013
2009 Three-Tier Prescription Drug List Reference Guide Your UnitedHealthcare pharmacy benefit Tier 1 – Your Lowest-Cost Option offers flexibility and choice in finding the right This is your lowest copayment option. For the medication for you. always consider Tier 1 medications if you andyour doctor decide they are right for yourchoices and make informed decisions. Tier 2 – You
De D n e t n a t l a lR e R g e i g s i t s r t a r t a i t o i n o n a n a d n d H i H s i t s o t r o y r 1 Patient Information 2 Dental Insurance Who is responsible for this account? __________________________Date ___________