Pfizer Patient Assistance Program

1 The Pfizer Patient Assistance Program is a joint Program of Pfizer Inc. and the Pfizer Patient Assistance Foundation . The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal Box 220040, Charlotte, NC 28222 T: 844-722-6672 F: 844-482-4482PP-PXP-USA-0002 2021 Pfizer Inc. All rights reserved. September 2021 Pfizer Patient Assistance ProgramApplication for patients For details about how we collect and use personal information, including applicable state privacy rights and notices for California residents, please visit application form is for patients who would like to apply to receive INFLECTRA (infliximab-dyyb) for Injection or RUXIENCE (rituximab-pvvr)

2 For rheumatoid arthritis, for free through the Pfizer Patient Assistance I Qualify for Assistance ?To qualify for Assistance , you mustHave been prescribed INFLECTRA or RUXIENCE for rheumatoid arthritis (For help with any other Pfizer medicines, or to learn about Pfizer s other Assistance programs , please call 844-989-PATH (7284) to speak with a Medicine Access Counselor (M F, 8 am 6 pm ET) Live in the United States (US) or a US territoryMeet one of the following: Meet certain income limitsHave no insurance coverage or not enough coverage to pay for your Pfizer medicine listed above Apply in the event your insurance denies coverage for your Pfizer medicineHow Can I Apply?)

3 If you need immediate Assistance with INFLECTRA or RUXIENCE, please call Pfizer enCompass at 844-722-6672 (M F, 8 am 8 pm ET)Please follow the checklist below when submitting your :Fill out and sign the Patient section of this enrollment your prescriber to fill out and sign the prescriber section and complete the prescription/order section of this enrollment the following required documents:Completed and signed application (pages 2 6)Note: Your prescriber should also keep a copy of your signed HIPPA form on page 4 in your photocopy of one of the following documents that shows your total annual income (if you do not want your income to be verified electronically).

4 Previous year s federal tax return (Form 1040 or 1040EZ) Wage and tax statements (W-2 forms) Two recent paycheck stubs Social security, pension, or railroad retirement statements (SSA-1099 or similar) Statements of interest, dividends, or other income (1099-INT, 1099, 1099-DIV, or similar forms)Make a photocopy of your application form and income documentation, if provided, as they typically will not be returned to youHave your prescriber fax or mail your application to: Pfizer Patient Assistance Program for Pfizer enCompass Box 220040 Charlotte, NC 28222 Fax: 844-482-4482[1]The Pfizer Patient Assistance Program is a joint Program of Pfizer Inc.

5 And the Pfizer Patient Assistance Foundation . The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal Box 220040, Charlotte, NC 28222 T: 844-722-6672 F: 844-482-4482PP-PXP-USA-0002 2021 Pfizer Inc. All rights reserved. September 2021 Patient SECTION1 Patient INFORMATIONP atient Name: Patient Address: City: State: Zip Code:Email: Telephone.

6 DOB (MM/DD/YY):Total number of people within household (including applicant): Total annual income for entire household:Please submit documentation to support the financial information if you do not want your income to be verified electronically. Attached is: Most recent federal tax return W-2 form OtherDo you have prescription or insurance coverage?Yes (If yes, please complete section 2 if you have not already submitted a Pfizer enCompass Enrollment Form)No (If no, skip section 2)2 PRESCRIPTION COVERAGE AND INSURANCE INFORMATIONIs INFLECTRA or RUXIENCE covered on your prescription or insurance plan?

7 Yes NoPrescription Co-Pay/Cost (if known):Please check the one box that best describes your coverage type: Medicare Medicare Part D Medicaid Private/Employer State Insurance Marketplace OtherPrimary Insurance Co. Name: Phone #:Policyholder Name: Policyholder DOB:Policyholder SSN: Member ID or Policy #: Group #:Prescription Card Name: Phone #:RxBin #: PCN #: Member ID or Policy #: Group #:Secondary Insurance Co.

8 Name: Phone #:Policyholder Name: Policyholder DOB:Policyholder SSN: Member ID or Policy #: Group #:Prescription Card Name: Phone #:RxBin #: PCN #: Member ID or Policy #: Group #:If the Patient is insured through a Medicare Prescription Drug Plan, please include the full plan address:Are you enrolled in a Medicare Part D Prescription Drug Plan?

9 Yes NoIf yes, provide your Medicare ID ( Patient s Health Insurance Claim Number (HICN) or Medicare Beneficiary Number (MBI)):If yes, provide your Medicare Part D Plan name and full address and provide a copy of the front and back of your Medicare Part Dcard with your enrollment form:Address: City: State: Zip Code:2(Do not submit medical records with the application)[2]The Pfizer Patient Assistance Program is a joint Program of Pfizer Inc.

10 And the Pfizer Patient Assistance Foundation . The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal Box 220040, Charlotte, NC 28222 T: 844-722-6672 F: 844-482-4482PP-PXP-USA-0002 2021 Pfizer Inc. All rights reserved. September 2021 Patient SECTION3 Patient PRIVACY AND CONSENT (Read and sign below)The information you provide will be used by Pfizer , the Pfizer Patient Assistance Foundation , and parties acting on their behalf to determine eligibility, to manage and improve Pfizer s Assistance programs , to communicate with you about your experience with Pfizer s Assistance programs , and/or to send you materials and other helpful information and updates relating to Pfizer Assistance programs .