Co-pay card Activation

Co-pay card Activation

ACTIVATE YOUR RELPAX $4 SAVINGS CARD

To activate your RELPAX $4 Savings Card, fill out the form below and enter your 12-digit ID number located on the back of your card.

Terms and Conditions apply.
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#Some exclusions apply. See full Terms and Conditions. Please note: This co-pay card is not health insurance and is only accepted at participating pharmacies. Savings limited to $150 per month for 12 uses. Card may be used once per month. For help with the RELPAX $4 Co-pay Card, call 1-800-926-5334, or write: Pfizer, ATTN: RELPAX, PO Box 4937, Warren, NJ 07059. www.pfizer.com
Text to save on Relpax (eletripan HBr)Text to save on Relpax (eletripan HBr)

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IMPORTANT SAFETY INFORMATION

Do not take RELPAX® (eletriptan HBr) if you:

  • Have heart disease or a history of heart disease
  • Have a history of stroke, transient ischemic attack
  • Have a history or current evidence of hemiplegic or basilar migraines (if you are not sure about this, ask your doctor)
  • Have peripheral vascular disease (e.g. narrowing of blood vessels to the legs, arms, stomach, intestines, or kidneys)
  • Have ischemic bowel disease (inadequate blood supply to the intestine)
  • Have uncontrolled blood pressure
  • Have taken other migraine medications in the last 24 hours, including other triptans, ergots, or ergot-type medications
  • Are allergic to RELPAX or any of its ingredients
  • RELPAX should not be used within at least 72 hours of treatment with the following medicines: Nizoral® (ketoconazole), Sporanox® (itraconazole), Serzone® (nefazodone), TAO® (troleandomycin), Biaxin® (clarithromycin), Norvir® (ritonavir), and Viracept® (nelfinavir)

All brands are trademarks of their owners.

Patients taking RELPAX may experience serious side effects, including:

Heart attacks and other heart problems. Heart problems may lead to death. Stop taking RELPAX and get emergency medical help right away if you have any symptoms of heart attack like discomfort in the center of your chest that lasts for more than a few minutes, or that goes away and comes back; chest pain or chest discomfort that feels like an uncomfortable heavy pressure; squeezing, fullness, or pain; pain or discomfort in your arms, back, neck, jaw, or stomach; shortness of breath with or without chest discomfort; breaking out in a cold sweat; nausea or vomiting; feeling lightheaded.

Medication overuse headaches. Some patients who take too many RELPAX may have worse headaches. If your headaches get worse your doctor may decide to stop your treatment with RELPAX.

Serotonin syndrome is a serious and life-threatening problem that can happen when taking RELPAX, especially when used with certain medications commonly used to treat depression such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). Tell your doctor right away if you experience mental changes such as hallucinations, fast heartbeat, high body temperature, trouble walking, or nausea, vomiting or diarrhea.

Changes in color or sensation in your fingers and toes (Raynaud’s syndrome).

Stomach and intestinal problems like sudden or severe stomach pain, stomach pain after meals, weight loss, nausea or vomiting, constipation or diarrhea, bloody diarrhea, fever.

Problems with blood circulation to your legs and feet (cramping and pain in your legs or hips); like feeling of heaviness or tightness in your leg muscles, burning or aching in your feet or toes while resting, numbness, tingling, or weakness in your legs, cold feeling or color changes in 1 or both legs or feet.

Most common side effects are dizziness, nausea, weakness, tiredness and drowsiness. If you have these symptoms, do not drive a car or do anything where you need to be alert. Tell your doctor about any side effects you have.

RELPAX should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

INDICATION

RELPAX (eletriptan HBr) is indicated for the acute treatment of migraine with or without aura in adults. RELPAX should only be used where a clear diagnosis of migraine has been established. RELPAX is not for the prevention of migraines or other types of headaches, including cluster headache.

TERMS AND CONDITIONS

By using the RELPAX $4 Co-pay Card, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

  • Co-pay cards are not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, or other federal or state healthcare programs (including any state prescription drug assistance programs and the Government Health Insurance Plan available in Puerto Rico [formerly known as "La Reforma De Salud"]).
  • Co-pay cards are not valid for prescriptions that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs that reimburse you for the entire cost of your prescription drugs.
  • Patients must be 18 or older.
  • By using a co-pay card, a patient may pay as little as $4 per prescription. Savings provided by each co-pay card are limited to $150 per month. Each co-pay card may be used once per month for twelve (12) months. Provided you continue to meet the eligibility criteria, you may be eligible to receive a second co-pay card during the offering.
  • Each patient is limited to one active co-pay card at a time during this offering period, and the co-pay cards are not transferable.
  • You must deduct the value received under this program from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf.
  • This co-pay card is not valid for Massachusetts residents whose prescriptions are covered in whole or in part by third-party insurance.
  • This co-pay card is not valid where prohibited by law.
  • The co-pay card cannot be combined with any other rebate or coupon, free trial, or similar offer for the specified prescription.
  • The co-pay card will be accepted only at participating pharmacies.
  • The co-pay card is not health insurance.
  • Offer valid only in the U.S. and Puerto Rico.
  • Pfizer reserves the right to rescind, revoke, or amend the co-pay card without notice.
  • Offer valid until 12/31/18. No membership fees apply.

For help with the RELPAX $4 Co-pay Card, call 1-800-926-5334, or write: Pfizer, ATTN: RELPAX, PO Box 4937, Warren, NJ 07059. www.pfizer.com

Click here for the full Prescribing Information and Patient Information for RELPAX.

You may report an adverse event related to Pfizer products by calling 1-800-438-1985 (U.S. only). If you prefer, you may contact the U.S. Food and Drug Administration (FDA) directly. The FDA has established a reporting service known as MedWatch where healthcare professionals and consumers can report serious problems they suspect may be associated with the drugs and medical devices they prescribe, dispense, or use. Visit MedWatch or call 1-800-FDA-1088.