Pfizer enCompass™ Enrollment Form for

INFLECTRA® (infliximab-dyyb) for Injection

Please complete and fax this form to 1-844-482-4482 or mail to: Pfizer enCompass, PO Box 220040, Charlotte, NC 28222
For assistance or additional information, call: 1-844-722-6672, Monday–Friday, 9 am–8 pm ET
For enrollment into the Pfizer Patient Assistance Program or Drug Replacement Program, complete the Pfizer Patient Assistance Program Application
available at www.pfizerencompass.com or by calling Pfizer enCompass.
Please check the appropriate box(es) and complete the enrollment form
Benefit verification and/or prior authorization support Pfizer enCompass Co-Pay Assistance Program (Complete sections 1-7) Referral for Interim Assistance
(Complete sections 1-4, 6) (Complete sections 1-6)

1. PATIENT INFORMATION 4. HEALTHCARE PROVIDER INFORMATION

*INDICATES REQUIRED FIELDS *INDICATES REQUIRED FIELDS

*NAME (FIRST, MIDDLE INITIAL, LAST) *REFERRING PROVIDER NAME (FIRST, LAST)
*DATE OF BIRTH
(MM/DD/YYYY) *GENDER MALE FEMALE SPECIALTY *NPI # STATE LICENSE #

*ADDRESS *PRACTICE NAME *TAX ID #

*CITY *STATE *ZIP CODE *OFFICE CONTACT

*PRIMARY PHONE *ADDRESS

PREFERRED
LANGUAGE EMAIL *CITY *STATE *ZIP CODE

CAREGIVER NAME *PHONE FAX

CAREGIVER PHONE H W C *EMAIL

My caregiver has consented to have Pfizer enCompass communicate directly
TREATMENT SITE OF SERVICE PHYSICIAN OFFICE HOSPITAL OUTPATIENT
with them on my behalf.
HOME INFUSION/INFUSION CENTER
2. CLINICAL INFORMATION
ADMINISTERING PROVIDER INFORMATION
PRIMARY ICD-10-CM DIAGNOSIS CODE (IF DIFFERENT FROM REFERRING PROVIDER)
Administering provider administers and oversees the product infusion
SECONDARY ICD-10-CM DIAGNOSIS CODE

Please list all current treatments and any prior treatments associated with the indications provided above.
*ADMINISTERING PROVIDER NAME (FIRST, LAST)
Treatment Length (mm/yyyy)
List Current/Prior Treatments
From To SPECIALTY *NPI # STATE LICENSE #
1. Methotrexate Y N
*PRACTICE NAME *TAX ID #
2.

3. *OFFICE CONTACT

4.
*ADDRESS
5.
*CITY *STATE *ZIP CODE
TB/PPD TEST DATE POS NEG

HEP B TEST DATE (OPTIONAL) POS NEG *PHONE *FAX

*EMAIL
3. INSURANCE INFORMATION *INDICATES REQUIRED FIELDS
PLEASE PROVIDE COPIES OF BOTH SIDES OF THE PATIENT’S INSURANCE CARD(S)
5. BILLING ADDRESS FOR PAYMENT FROM THE PFIZER
*PRIMARY INSURANCE NAME
ENCOMPASS CO-PAY ASSISTANCE PROGRAM, IF
*INSURANCE COMPANY PHONE DIFFERENT FROM ADMINISTERING PROVIDER
*INDICATES REQUIRED FIELDS
*POLICY ID# *GROUP #

*POLICYHOLDER NAME
*PRACTICE BILLING OFFICE NAME
*DATE OF BIRTH
*RELATIONSHIP TO PATIENT (MM/DD/YYYY)
*PRACTICE BILLING OFFICE CONTACT
SECONDARY INSURANCE
*PRACTICE BILLING ADDRESS
INSURANCE COMPANY PHONE
*CITY *STATE *ZIP CODE
POLICY ID# GROUP #

POLICYHOLDER NAME *PRACTICE BILLING PHONE

RELATIONSHIP TO PATIENT DATE OF BIRTH *EMAIL

(MM/DD/YYYY)
PREFERRED SPECIALTY PHARMACY
1 of 2
 Pfizer enCompass™ Enrollment Form for
INFLECTRA® (infliximab-dyyb) for Injection

6. Healthcare Provider Consent

By signing this enrollment form, I certify that therapy with INFLECTRA is medically necessary for this patient. I will be supervising the patient’s treatment accordingly, and I have reviewed the
current INFLECTRA prescribing information. I have received the necessary authorization to release medical and/or other patient information relating to INFLECTRA therapy to Pfizer Inc and its
agents, affiliates, representatives, and service providers to use and disclose as necessary to enroll my patient into Pfizer enCompass. I have informed my patient or their caregiver that I will provide
his/her contact information to Pfizer enCompass, and I have received and obtained prior express consent from my patient or their caregiver for Pfizer enCompass to contact my patient or their
caregiver by phone for the purpose of providing insurance benefit verification services and identifying prescription payment assistance for which they may be eligible, including through the use of
an autodialer or prerecorded voice at the telephone number provided. I also give my permission to receive calls related to these services from Pfizer enCompass, Pfizer Inc, and parties calling on
their behalf, including calls made with an autodialer or prerecorded voice at the phone number(s) provided. Pfizer reserves the right to revise or terminate this program, in whole or in part, without
notice at any time.

PRINT NAME OF HEALTHCARE PROVIDER SIGNATURE OF HEALTHCARE PROVIDER DATE

7. Patient Consent and Attestation

I understand that the information I provided will be used by Pfizer enCompass, Pfizer, and/or parties acting on its behalf to determine my eligibility and provide benefit verification and
payment assistance services. I agree to be contacted by Pfizer enCompass, Pfizer Inc, and parties working on their behalf for these purposes using an autodialer or prerecorded voice at the
telephone number provided. I understand that I can opt-out of these communications at any time by contacting Pfizer enCompass at 1-844-722-6672.

Co-Pay Program Consent and Attestation: The checkboxes below must be completed if you are requesting enrollment in the Pfizer enCompass Co-Pay Assistance Program.

Yes No I authorize the Pfizer enCompass Co-Pay Assistance Program for INFLECTRA to provide payment directly to my healthcare provider, and not to me, for my out-of-pocket
drug costs for INFLECTRA. I authorize my healthcare provider to contact the Program on my behalf to initiate payment for services after they have been rendered. I understand that I will be
responsible for any out-of-pocket expenses for INFLECTRA if (1) my healthcare provider does not request payment within 120 days of the issue date on my Explanation of Benefits (EOB), or (2) if
I am deemed ineligible for reimbursement from the Program. To be eligible for this program, you must be commercially insured and not be enrolled in a state- or federally funded insurance program.
Please see full terms and conditions.

Yes No I certify that I am not covered by Medicaid, Medicare, or any 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”]).

PRINT PATIENT’S NAME SIGNATURE OF PATIENT DATE

If the patient is incapacitated (physically or mentally), obtain the following signatures below:

SIGNATURE OF PERSONAL REPRESENTATIVE DESCRIPTION OF AUTHORITY DATE

DISCLAIMER
Insurance verification is the ultimate responsibility of the provider. Benefit information provided by Pfizer enCompass is not a guarantee of insurance coverage or reimbursement. All benefit
information is subject to the insured patient’s plan at the time services are rendered. Under no circumstances shall Pfizer enCompass be held responsible or liable for payment of any claims,
benefits, or cost. Any coding information obtained from Pfizer enCompass is provided for informational purposes only, is subject to change, and should not be construed as legal advice. Providers
should exercise independent clinical judgment when selecting codes and submitting claims to accurately reflect the services and products furnished to the specific patient.
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 eligible 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.

PP-PAT-USA-0757 © 2018 Pfizer Inc. All rights reserved. Printed in USA/February 2018 2 of 2