![]() ![]() I understand that I do not need to sign this Authorization in order to receive health care treatment (including with Pfizer products) or insurance benefits, and that I may cancel the Authorization at any time by canceling at /consent. I understand that once disclosed pursuant to this authorization, my PHI may no longer be protected by federal law and could be re-disclosed to others, but I also understand that the Pfizer Group intends to safeguard my PHI and to use and disclose it only for the purposes described herein. If I previously provided consent for use and disclosure of my personal health information related to my treatment with Nurtec® ODT to Biohaven, I hereby authorize the use and sharing of that information (including by Biohaven to the Pfizer Group) in the same manner and to the same extent as my PHI as defined above. I authorize the Pfizer Group to use my Information, and to share it among themselves and with my Healthcare team, for the forgoing purposes. ("Pfizer") and its vendors (collectively, the "Pfizer Group"), my personal health information, including my contact information and information on my medical condition, treatment, and insurance coverage (collectively, my "PHI") so that the Pfizer Group may use the PHI to (i) assess my qualification for copay support, (ii) provide support and resources related to my insurance coverage, financial assistance and adherence, (iii) contact me to provide me with information related to my treatment with Pfizer products, including promotional information if I also provide additional consent to receive marketing communications, and (iv) to monitor and evaluate the implementation and effectiveness of the services provided by the Pfizer Group. If you had previously provided your consent for Pfizer to use your protected health information, you can opt out at /consent.īy checking the box below this Authorization, I authorize my health care provider(s) (including pharmacies) and health plans (my "Healthcare Team"), to disclose to Pfizer Inc. Pfizer reserves the right to rescind, revoke or amend this offer without notice.Data shared with Pfizer will be aggregated and de-identified it will be combined with data related to other copay card redemptions and will not identify you. Data related to your redemption of the copay card may be collected, analyzed and shared with Pfizer for market research and other purposes related to assessing Pfizer’s programs.Copay card is limited to 1 per person during this offering period and is not transferable.This copay card is not health insurance.Copay card will be accepted only at participating pharmacies.The copay card cannot be combined with any other savings, free trial, or similar offer for the specified prescription.This copay card is not valid where prohibited by law.You must be 18 years of age or older to redeem the copay card under this program.You should not use the copay card if your insurer or health plan prohibits use of manufacturer copay cards. You are responsible for reporting use of the copay card to any private/commercial insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the copay card, as may be required.You must deduct the value of this copay card from any reimbursement request submitted to your private/commercial insurance plan, either directly by you or on your behalf.This copay card and rebate are not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private/commercial insurance plan or other private/commercial health or pharmacy benefit programs.The copay card may not be redeemed more than once per 30 days per patient. Eligible patients with commercial insurance and a script for Nurtec ODT may pay as little as $0 out of pocket for a 30-day supply.Offer is not valid for cash paying patients. Patient must have private/commercial insurance.Patients are not eligible to use this card 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").By using this copay card, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below: ![]()
0 Comments
Leave a Reply. |
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |