Pfizer enCompass Enrollment Form for INFLECTRA …

1 Please complete and fax this form to 1-844-482-4482 or mail to Pfizer Inc. ( Pfizer ) at Pfizer enCompass , PO Box 220040, Charlotte, NC 28222 For assistance call: 1-844-722-6672, Monday Friday, 8 am 8 pm ETFor details about how we collect and use personal information, including applicable state privacy rights and notices for California residents, please visit enCompass Enrollment form for INFLECTRA (infliximab-dyyb) for Injection and RUXIENCE (rituximab-pvvr)For Enrollment into the Pfizer Patient Assistance Program, complete the Pfizer Patient Assistance Program Application available at or by calling Pfizer enCompass .

2 *NAME (FIRST, MI, LAST) *SEX MALE FEMALE *STREET ADDRESS *CITY *STATE *ZIP *DATE OF BIRTH (MM/DD/YY) EMAIL *PHONE 1. PATIENT INFORMATION (TO BE COMPLETED BY PATIENT) *INDICATES REQUIRED FIELDSLANGUAGE PREFERENCE*INSURANCE NAME *INSURANCE PHONE *POLICY/GROUP ID NUMBER*POLICYHOLDER NAME PATIENT CAREGIVERCHECK HERE IF PATIENT DOES NOT HAVE INSURANCECHECK HERE IF PATIENT HAS SECONDARY INSURANCE1 of 4 Benefit verification and/or prior authorization support (Complete sections 1-4, 7)

3 Pfizer enCompass Co-Pay Assistance Program (Complete sections 1-7)(For INFLECTRA only)Referral for Interim Assistance (Complete sections 1-4, 7)Please check the appropriate box(es) and complete the Enrollment INCLUDE A COPY OF THE FRONT AND BACK OF THE PATIENT S INSURANCE CARD(S)CAREGIVERNAMECAREGIVERPHONE2. CLINICAL INFORMATION (TO BE COMPLETED BY PATIENT OR HEALTHCARE PROVIDER) *INDICATES REQUIRED FIELDS3. INSURANCE INFORMATION (TO BE COMPLETED BY PATIENT OR HEALTHCARE PROVIDER) *INDICATES REQUIRED FIELDSPRIMARY INSURANCE *POLICYHOLDER RELATIONSHIP TO PATIENT*POLICYHOLDER DATE OF BIRTH (MM/DD/YY)PREFERRED SPECIALTY PHARMACY SELF-DISPENSING PHARMACYThe patient identified above prefers use of the Specialty Pharmacy indicated above.

4 I authorize Pfizer and its affiliates, agents, representatives, and service providers to fax this prescription to the Specialty Pharmacy designated above, provided it is approved by this patient s plan. If the Specialty Pharmacy designated is not a plan-approved Specialty Pharmacy, then fax to a Specialty Pharmacy approved by this patient s plan. If there is no preferred Specialty Pharmacy indicated, then fax to any Specialty Pharmacy approved by this patient s plan. *PREFERRED SPECIALTY PHARMACY NAMEPRESCRIPTION INSURANCE NAME PRESCRIPTION POLICY ID NUMBER PRESCRIPTION GROUP ID NUMBER PRESCRIPTION BIN PRESCRIPTION PCN PRESCRIPTION INSURANCE *INSURANCE NAME *INSURANCE PHONE *POLICY/GROUP ID NUMBER*POLICYHOLDER NAME SECONDARY INSURANCE *POLICYHOLDER RELATIONSHIP TO PATIENT*POLICYHOLDER DATE OF BIRTH (MM/DD/YY)

5 INFLECTRA 100 mg vial RUXIENCE* 100 mg/10 mL SDVP lease check product:* Pfizer enCompass supports patients prescribed INFLECTRA and RUXIENCE for Rheumatoid Arthritis (RA). Patients prescribed RUXIENCE for FDA-approved oncology indications may be supported by Pfizer Oncology Together. For more information, visit RUXIENCE* 500 mg/50 mL SDV*PRIMARY DIAGNOSIS CODE SECONDARY DIAGNOSIS CODE DATE OF INFUSION Pfizer enCompass Enrollment form for INFLECTRA (infliximab-dyyb) for Injection and RUXIENCE (rituximab-pvvr)*PRINT NAME OF PATIENT PATIENT SIGNATUREDATE 5.

6 PATIENT CONSENT TO RECEIVE COMMUNICATIONSBy signing this form , I agree to communications from Pfizer , Pfizer enCompass , and/or parties acting on their behalf to determine my eligibility and provide benefits verification, prior authorization/appeals assistance, and financial assistance resources and information, such as co-pay support or free drug programs, and for other non-marketing purposes. I agree to be contacted by Pfizer , Pfizer enCompass , or parties working on their behalf for these purposes using an autodialer or prerecorded voice at the telephone number(s) provided. If I have a caregiver, he or she has also agreed to receive such communications from Pfizer , Pfizer enCompass , and/or parties acting on their behalf for the purposes described above, and I hereby give my permission for Pfizer , Pfizer enCompass , and/or parties acting on their behalf to contact my caregiver for such purposes.

7 I understand that I (and, if applicable, my caregiver) can opt out of these communications at any time by contacting Pfizer enCompass at 1-844-722-6672, Monday Friday, 8 am 8 pm AND CONDITIONST erms and Conditions: By using this program, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions below:The Pfizer enCompass Co-Pay Assistance Program for INFLECTRA and RUXIENCE is not valid for patients that 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 ).

8 Program offer is not valid for cash-paying patients. Patients prescribed RUXIENCE for pemphigus vulgaris are not eligible for this co-pay savings program. With this program, eligible patients may pay as little as $0 co-pay per INFLECTRA or RUXIENCE treatment. There are specific maximum annual patient savings for each product, which range from $20,000 ( INFLECTRA ) to $25,000 (RUXIENCE) for out-of-pocket expenses for the respective product including co-pays or coinsurances. The amount of any benefit is the difference between your co-pay and $0. After the maximum benefit, you will be responsible for the remaining monthly out-of-pocket costs.

9 Patient must have private insurance with coverage of INFLECTRA or RUXIENCE. 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 private health or pharmacy benefit programs. You must deduct the value of this assistance 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 program to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the program, as may be required.

10 You should not use the program if your insurer or health plan prohibits use of manufacturer co-pay assistance programs. This program is not valid where prohibited by law. This program cannot be combined with any other savings, free trial or similar offer for the specified prescription. Co-pay card will be accepted only at participating pharmacies. This program is not health insurance. This program is good only in the and Puerto Rico. This program is limited to 1 per person during this offering period and is not transferable. No other purchase is necessary. Data related to your redemption of the program assistance may be collected, analyzed, and shared with Pfizer , for market research and other purposes related to assessing Pfizer s programs.