Eligible, commercially insured patients may pay as little as $0 a month for
BOSULIF (bosutinib). Limits, terms, and conditions apply. See below for
details.

Form Section

Fieldset 1

CHECK YOUR ELIGIBILITY

Please select “yes” or “no” for the following questions.

Your answers will determine your eligibility for the Pfizer Co-Pay Savings Program.

Eligible, commercially insured patients may pay as little as $0 a month for BOSULIF (bosutinib). Limits, terms, and conditions apply. See below for details.

are_you_18_years_of_age_or_older_wrapper
Are you 18 years of age or older?
Do you live in US wrapper
Do you currently live in the United States or Puerto Rico?
Purchase prescription medication wrapper
Do you purchase your prescription medication through a federal or state prescription drug program, such as Medicare or Medicaid?
Fieldset 2

Co-Pay Card Terms and Conditions

By using this co-pay card, you acknowledge that you currently meet the eligibility criteria and will comply with the Terms and Conditions described below:

  • 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 (formerly known as "La Reforma de Salud").
  • Patient must have private insurance. Offer is not valid for cash-paying patients.
  • With this card, eligible patients will pay a $0 co-pay per eligible monthly prescription, subject to a maximum amount of $25,000 per calendar year. The amount of any benefit is the difference between your co-pay and $0. After the annual maximum of $25,000 is reached, you will be responsible for the remaining monthly out-of-pocket costs. This card may not be redeemed more than once per 30 days.
  • This co-pay card is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plan or other private health or pharmacy benefit programs.
  • You must deduct the value of this co-pay card from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf.
  • You are responsible for reporting use of the co-pay card to any private insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the co-pay card, as may be required. You should not use the co-pay card if your insurer or health plan prohibits use of manufacturer co-pay cards.
  • You must be 18 years of age or older to redeem the co-pay card.
  • This co-pay card is not valid where prohibited by law.
  • Card cannot be combined with any other savings, free trial, or similar offer for the specified prescription.
  • Card will be accepted only at participating pharmacies.
  • This card is not health insurance.
  • Offer good only in the U.S. and Puerto Rico.
  • Card 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 co-pay card may be collected, analyzed, and shared with Pfizer for market research and other purposes related to assessing Pfizer’s programs. Data shared with Pfizer will be aggregated and de-identified; it will be combined with data related to other co-pay card redemptions and will not identify you.
  • Pfizer reserves the right to rescind, revoke, or amend this offer without notice.
  • Offer expires 12/31/2020.
  • If your pharmacy does not participate, you may be able to submit a request for a rebate in connection with this offer. Mail a copy of the patient’s pharmacy receipt indicating patient name, name of medication purchased, price paid, and date purchased, along with a copy of the patient’s Pfizer Oncology Together Co-Pay Savings Card, to:

Pfizer Oncology Together Co-Pay Savings Program
2250 Perimeter Park Drive, Suite 300
Morrisville, NC 27560

Important Information: Embedded Bottom

Important Safety Information And Indications

Do not take BOSULIF if you are allergic to bosutinib or any of the ingredients in BOSULIF.
Before you take BOSULIF, tell your doctor if you:
  • have liver problems
  • have heart problems
  • have kidney problems
  • have any other medical conditions
  • are pregnant or plan to become pregnant. BOSULIF can harm your unborn baby. Tell your doctor right away if you become pregnant while taking BOSULIF
    • Females who are able to become pregnant should have a pregnancy test before starting treatment with BOSULIF and should use effective birth control (contraception) during treatment with BOSULIF and for at least 2 weeks after the last dose. Talk to your doctor about birth control methods that may be right for you
  • are breastfeeding or plan to breastfeed. It is not known if BOSULIF passes into your breast milk or if it can harm your baby. Do not breastfeed during treatment with BOSULIF and for at least 2 weeks after the last dose

Tell your doctor about the medicines you take, including prescription medicines, nonprescription medicines, vitamins, and herbal supplements. BOSULIF and certain other medicines can affect each other.

BOSULIF may cause serious side effects, including:
  • Stomach problems. BOSULIF may cause stomach (abdomen) pain, nausea, diarrhea, vomiting, or blood in your stools. Get medical help right away for any stomach problems
  • Low blood cell counts. BOSULIF may cause low platelet counts (thrombocytopenia), low red blood cell counts (anemia), and low white blood cell counts (neutropenia). Your doctor should do blood tests to check your blood cell counts regularly during your treatment with BOSULIF. Call your doctor right away if you have unexpected bleeding or bruising, blood in your urine or stools, fever, or any signs of an infection
  • Liver problems. BOSULIF may cause liver problems. Your doctor should do blood tests to check your liver function regularly during your treatment with BOSULIF. Call your doctor right away if your skin or the white part of your eyes turns yellow (jaundice) or you have dark “tea color” urine
  • Heart problems. BOSULIF may cause heart problems, including heart failure. Get medical help right away if you get shortness of breath, weight gain or swelling in your hands, ankles or feet
  • Your body may hold too much fluid (fluid retention). Fluid may build up in the lining of your lungs, the sac around your heart, or your stomach cavity. Get medical help right away if you get any of the following symptoms during your treatment with BOSULIF:

shortness of breath and cough

chest pain

swelling in your hands, ankles, or feet

swelling all over your body

weight gain

  • Kidney problems. BOSULIF may cause kidney problems. Your doctor should do tests to check your kidney function when you start treatment with BOSULIF and during your treatment. Call your doctor right away if you get any of the following symptoms during your treatment with BOSULIF:

you urinate more or less often than normal

you make a much larger or smaller amount of urine than normal

The most common side effects of BOSULIF for those patients who are newly diagnosed include: diarrhea, nausea, low platelet counts, rash, stomach pain, and changes in liver function tests.

The most common side effects of BOSULIF for those patients who no longer benefit from or did not tolerate other treatment include: diarrhea, nausea, stomach pain, rash, low platelet counts, vomiting, low red blood cell counts, tiredness, fever, cough, headache, changes in liver function tests, and swelling.

Tell your doctor or get medical help right away if you get respiratory tract infections, loss of appetite, headache, dizziness, back pain, joint pain, or itching while taking BOSULIF. These may be symptoms of a severe allergic reaction.

Your doctor may change your dose, temporarily stop, or permanently stop treatment with BOSULIF if you have certain side effects.

BOSULIF may cause fertility problems in both female and male patients. This may affect your ability to have a child. Talk to your doctor if this is a concern for you.

Tell your doctor if you have any side effect that bothers you or that does not go away. These are not all of the possible side effects of BOSULIF. For more information, ask your doctor or pharmacist. You may report side effects to FDA at 1-800-FDA-1088.

INDICATIONS

BOSULIF is a prescription medicine used to treat adults who have a certain type of leukemia called Philadelphia chromosome–positive chronic myelogenous leukemia
(Ph+ CML):

  • Who are newly diagnosed. The approval of BOSULIF in these patients was based on molecular and cytogenetic response rates. There is an ongoing clinical study to confirm clinical benefit
  • Who no longer benefit from or did not tolerate other treatment

Pfizer Oncology