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Patient Assistance Information

 
4 Programs Sponsored By Pfizer (External Link)
 
 
Pfizer RxPathways Patient Assistance Program

PO Box 66585
St. Louis, MO 63166-6585
Phone : (866)706-2400
Fax: (866)470-1748
Eligibility
> The patient must either have no prescription coverage, or not enough coverage, to pay for their prescribed Pfizer medicine(s). Income requirements for this program have not been disclosed. Patients must reside in the US, Puerto Rico or USVI.
Who Can Apply
> Anyone who has been prescribed a Pfizer medicine and is in need of assistance can call or download an application.
Required
> The doctor must fill out a section and sign. The patient must fill out a section, sign the application and attach proof of income.
Supply
> Varies
Ship To
> Varies
Note
>
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Aromasin
Arthrotec Tablets (diclofenac sodium/misoprostol)
Benefix injection
Bosulif (bosutinib) tablets
Caduet Tablets
Camptosar
Caverject Injection (alprostadil)
Celebrex Capsules
Celontin Capsules
Chantix
Cleocin Capsules
Cleocin Pediatric Oral Suspension
Cleocin Phosphate injection
Cleocin T lotion; topical
Cleocin T solution; topical
Colestid Granules
Colestid Tablets
Depo SubQ Provera Injection
Depo-Estradiol Injection
Depo-Medrol Injection
Detrol LA Capsules
Detrol Tablets
Dilantin capsule; extended release
Dilantin Capsules
Dilantin tablet; chewable
Dilantin-125 oral suspension
Duavee tablet
Effexor XR capsule; extended release
Ellence Injection
Emcyt capsule
Estring Vaginal Ring
Glyset Tablets
Ibrance
Idamycin PFS injection
Inlyta tablet
Inspra Tablets
Lincocin injection
Lyrica Capsules
Mycobutin Tablets (rifabutin)
Nardil Tablets
Nicotrol Inhaler
Nitrostat tablet
Norpace Capsules
Premarin cream; vaginal
Premarin tablet
Premphase tablet
Prempro tablet
Prevnar 13 vaccine
Pristiq tablet; extended release
Procardia Capsules
Procardia XL Capsules (Nifedipine)
Quillivant XR suspension; extended release
Rapamune oral solution
Rapamune tablet
Relpax Tablets
Revatio tablet
Skelaxin (metaxalone)
Sutent Capsule
Synarel Nasal Spray
Tikosyn Tablets (dofetilide)
Torisel solution; iv
Toviaz tablet; extended release
Trecator tablet
Vantin Oral Solution (cefpodoxime proxetil)
Vfend
Viagra Tablets
Xalatan
Xalkori capsule
Xyntha Solofuse iv
Zarontin
Zinecard injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
Download printable Form
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader
 
 
Pfizer Bridge Program

P.O. Box 220746
Charlotte, NC 28222
Phone : 800-645-1280
Fax: 800-479-2562
Eligibility
> The patient must be uninsured or underinsured and meet income guidelines that are not disclosed. The medication must be used for a FDA-approved diagnosis.The patient must also be a US resident.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application.
Required
> The doctor must complete and sign the Statement of Medical Necessity Form. The patient must complete and sign the application and the Patient Authorization Form.
Supply
> Up to a 30-day supply
Ship To
> Patient's home
Note
> With the patient's permission, anyone concerned can call for an application.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Genotropin
Somavert injection
 
 
 
Lipitor Choice Co-Pay Program

LIPITOR Choice Card
14001 Weston Parkway, Suite 103
Cary, NC 27513
Phone : 800-314-7957
Fax:
Eligibility
> This is a copay assistance program for patients that have private insurance. Patients with government funded insurance are not eligible. Patient with Medicare Part D are eligible but must contact the program for details. There are no income requirements for this program. MA residents are not eligible.
Who Can Apply
> Patients or healthcare providers can call to complete by phone or complete online.
Required
> Patients must enroll online or by phone and doctors must provide a prescription.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> Program expires 12/31/16 This card is only valid at participating pharmacies. The maximum savings is $2500 per year. To qualify for this offer your out-of-pocket expense must be more than $4 per prescription.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Lipitor Tablets
 
 
 
Xelsource Answers and Support for Xeljanz

2730 S. Edmonds Lane, Suite 300,
Lewisville, TX 75067
Phone : 855-493-5526
Fax: 866-297-3471
Eligibility
> Patients must be uninsured or underinsured. Medicare Part D recipients are also eligible. Income requirements for this program vary. Patients must live in the US.
Who Can Apply
> Patients or healthcare professionals can call to have an application mailed or download the application.
Required
> Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income.
Supply
> Varies
Ship To
> Varies
Note
>
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Xeljanz tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader