Do not take PRISTIQ if you are allergic to desvenlafaxine, venlafaxine, or any of the ingredients in PRISTIQ. Do not take PRISTIQ if you currently take, or have taken within the last 14 days, any medicine known as an MAOI (including intravenous methylene blue or the antibiotic linezolid).

Activate Your
PRISTIQ Savings Card

If you’ve received a PRISTIQ Savings Card from your health care professional, activate it by filling out the fields below. You do not need to activate your card if you downloaded it online and received a permanent card in the mail.

Eligible patients save up to $15* on their monthly prescription.

*Terms & Conditions apply.
See details below

Savings Card Activation

Fill out the following form then click the “Submit” button.
All fields are required unless otherwise indicated.

Sorry, you must be 18 years or older.

Please enter your 11-digit PRISTIQ Savings Card ID number (located on the bottom left-hand corner of your card).

Are you 18 years or older?

Please make a selection.

Yes

No

Sorry, you are not eligible for the PRISTIQ Savings Card because you participate in Medicare, Medicaid, or a similar federal or state prescription drug program. Please see Terms and Conditions for details.

You are still eligible to receive Inside Depression^TM Updates, a free e-mail newsletter program. Learn more about Inside Depression^TM Updates.

Please check one of the following boxes to confirm your eligibility.

Do you purchase your prescription medication through Medicare, Medicaid, or a similar federal or state prescription drug program?

Please make a selection.

Yes

No

Your Contact Information

First Name
Last Name
E-mail
Confirm E-mail
Phone Number (optional)	- -
Gender (optional)	Male Female

Mailing Address

Address Line 1
Address Line 2
City
State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
ZIP Code

Pfizer understands your personal and health information is private. The information you provide will only be used by Pfizer and parties acting on its behalf to send you the materials you requested and other helpful information and updates on PRISTIQ, and/or depression in adults, as well as related treatments, products, offers and services.

By checking this box, I also agree that Pfizer or companies acting on its behalf may send me materials about other health conditions, use my information to develop or improve products and services, or contact me in the future about health-related topics.

I’d like to receive Inside DepressionTM Updates, a free e-mail newsletter program with education and support to help me stay focused on my commitment to feeling better. Learn More

Antidepressants increased the risk of suicidal thinking and behavior in children, teens, and young adults. Depression and certain other psychiatric disorders are themselves associated with increases in the risk of suicide. Patients of all ages who are started on antidepressant therapy or when the dose is changed should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior such as becoming agitated, irritable, hostile, aggressive, impulsive, or restless. Should these occur, report them to a doctor right away. PRISTIQ is not approved for use in children under 18.

*Terms and Conditions

By using the PRISTIQ Savings Card, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

• The Card is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, or other federal or state health care 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”).
• The Card is not valid for prescriptions that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs which reimburse you for the entire cost of your prescription drugs.
• You will save either $15 or the amount of your co-pay/out-of-pocket cost, whichever is less. Card can only be used for up to 12 prescriptions per year.
• 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.
• Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription.
• The Card will be accepted only at participating pharmacies.
• This Card is not health insurance.
• Offer good only in the U.S. and Puerto Rico.
• The Card is limited to one person during this offering period and is not transferable.
• Pfizer reserves the right to rescind, revoke, or amend the program without notice.
• No membership fees.
• Card and program expire 6/30/2014.

For more information about the savings card call 1-800-842-6031 or write to:

PRISTIQ Savings Card,
6501 Weston Parkway, Suite 370,
Cary, NC 27513