Welcome to the Pfizer Inflammation & Immunology (I&I) Co-Pay Portal

• 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, 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").
• 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 $4,000 to $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.
• Patients must be 18 years of age or older to redeem the Card.
• 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.
• The benefit under the Program is offered to, and intended for the sole benefit of, eligible patients and may not be transferred or utilized for the benefit of third parties, including, without limitation, third party payers, pharmacy benefit managers, or agents of either.
• This program cannot be combined with any other savings, free trial, or similar offer for the specified prescription (including any program offered by a third-party payer or pharmacy benefit manager, or 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 agents of either, are prohibited from assisting patients with enrolling in the Program.
• 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. Data shared with Pfizer will be aggregated and de-identified; it will be combined with data related to other Program redemptions and will not identify you.
• Pfizer reserves the right to rescind, revoke, or amend the Program without notice.
• Program expires 12/31/2026.

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.