Vyndamax® (tafamidis) Co-pay Eligibility Form

VYNDAMAX Co-Pay Savings Program

ELIGIBLE, COMMERCIALLY INSURED PATIENTS MAY
PAY AS LITTLE AS $0 PER MONTH FOR VYNDAMAX.*

Please verify the following information to receive a Co-Pay Savings Card:

The patient is 18 years of age or older.

The patient is not older than 65 years of age and retired, and if applicable, neither is their partner/spouse.

The patient does not receive Social Security Disability or any other Social Security Administration benefit.

The patient is not active-duty military, or a dependent or spouse of an active-duty military member.

The patient does not have insurance from any federal healthcare program (including Medicare, Medicaid, TRICARE^®, or any other state or federal medical pharmaceutical benefit program or pharmaceutical assistance program).

The patient is requesting to obtain and activate a VYNDAMAX Co-Pay Savings Card (if applicable, the patient has authorized me on their behalf).

The patient confirms all the requirements above*

Leave this field blank

Please review your selection. You must check the required box to proceed.

If you have any questions regarding eligibility, please call VyndaLink at 1-888-222-8475 Monday-Friday, 8 AM-8 PM ET.

Limits, terms, and conditions apply. 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^®, Veterans Affairs health care, a state prescription drug assistance program, or the Government Health Insurance Plan available in Puerto Rico. $10,000-$60,000 maximum program benefit per calendar year. The offer will be accepted only at participating pharmacies. This offer is not health insurance. No membership fees apply. Pfizer reserves the right to rescind, revoke, or amend this offer without notice. For any questions, please call 1-888-222-8475 or write: Pfizer, ATTN: Claims Processing Department, IQVIA, Inc. 77 Corporate Drive, Bridgewater, NJ 08807. Click here for full terms and conditions.

VYNDAMAX Co-Pay Savings Program

ELIGIBLE, COMMERCIALLY INSURED PATIENTS MAY PAY AS LITTLE AS $0 PER MONTH FOR VYNDAMAX.*

ELIGIBLE, COMMERCIALLY INSURED PATIENTS MAY
PAY AS LITTLE AS $0 PER MONTH FOR VYNDAMAX.*