Trial Prescription Program

Trial Prescription Program—Start your eligible patients on BeneFix

Trial Prescription Program allows your patient to get a one-time, 1-month supply up to 20,000 IU of Pfizer factor product delivered at no cost to him or her.

For first-time use by commercially insured patients only.

Getting started: How to enroll

1. Determine if your patient is eligible.

Your patient must be currently covered by a private (commercial) insurance plan. If your patient is not eligible for the Trial Prescription Program, you may find help accessing Pfizer factor medicines by contacting the Pfizer Hemophilia Connect Program at 1.844.989.HEMO(4366).

2. Download and complete the enrollment and authorization forms.

Direct your patient to download the appropriate forms. Your patient may also contact his or her local Pfizer Hemophilia Patient Affairs Liaison, or try our hotline number 1.844.989.HEMO(4366). To enroll, your eligible patient must read the terms and conditions and complete parts 1–4 of the form; parts 5–13 are to be completed by the physician.

3. Write a prescription and submit the forms.

Fax the completed form with the prescription and the patient authorization form to 1.888.868.8660. Fax must be sent from a health care provider’s office. You may also mail required documents to:

Trial Prescription Program Administrator, MedVantx
PO Box 5736
Sioux Falls, SD 57117-5736

Please allow 1 to 3 weeks after submission of forms for processing and delivery.

For questions about the Factor Product Trial Prescription Program, please call 1.844.989.HEMO(4366), Monday through Friday, 9:00 AM – 5:00 PM ET.

Download a compressive guide on financial support from Pfizer Hemophilia.

OFFER TERMS: By enrolling in the Pfizer Factor Product Trial Prescription Program, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

You are currently covered by a private [commercial] insurance plan. An original free trial offer and a valid prescription must be presented. No claim for reimbursement for Pfizer factor products dispensed pursuant to this free trial offer may be submitted to any third-party payor. Medicaid, Medicare, or any other federal or state health care program beneficiaries are not eligible for this offer (this includes any state prescription drug assistance programs and the Government Health Insurance Plan, available in Puerto Rico, formerly known as “La Reforma de Salud”). The free trial offer is not valid for prescriptions that are eligible to be reimbursed by private insurance plans or health or pharmacy benefit programs that reimburse you for the entire cost of your prescription drugs. This free trial offer is not valid where otherwise prohibited by law. You may receive a 1-month supply up to 20,000 IU of factor. The free trial offer cannot be combined with any other rebate/coupon, free trial, or similar offer for the prescribed prescription. The free trial offer will only be accepted by participating factor providers. This free trial offer is not health insurance. Offer good only in the U.S. and Puerto Rico. Only new patients may use this offer. By redeeming this offer, you certify that you are not currently using Pfizer factor products. Only 1 offer per person may be redeemed under this program. This offer is not transferable. Pfizer reserves the right to rescind, revoke, or amend this free trial offer without notice. Offer expires 1 month from enrollment date or when the maximum benefit up to 20,000 IU at no cost has been reached. No membership fees.

Terms and conditions apply.