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Patient Assistance Information

 
4 Programs for Zoloft (sertraline HCL)
 
 
Pfizer Connection to Care

PO Box 66585
St. Louis, MO 63166-6585
Phone : (866)706-2400
Fax: n/a
Eligibility
> The patient must either have no prescription coverage, or not enough coverage, to pay for their prescribed Pfizer medicine(s). The patient must also have an income at or below 200% of the Federal Poverty Level, adusted for family size, in order to qualify.
Who Can Apply
> Anyone who has been prescribed a Pfizer medicine and is in need of assistance can download an application and apply online and apply to the program.
Required
> The doctor must fill out a section, and in some cases, attach a prescription.The patient must fill out a section, sign the application and attach proof of income.
Supply
> Patients will receive their medicine in 90-day supplies throughout their enrollment. Healthcare providers can place medicine reorders online via www.PfizerPAP.com, or through Pfizer's automated phone reordering system at 1-855-742-7497. Healthcare providers can add a new medicine, or make a change to the dose of an existing medicine, for enrolled patients by completing a "Medicine Change Request Form" and faxing it to 1-866-470-1748.
Ship To
> Doctor's office, except for Lyrica, which is sent to Patient's home
Note
> The completed application must be mailed back. Both the patient and doctor are notified in writing of acceptance or denial. If a medication needs to be added or the dosage of medication needs changed for a patient during his/her enrollment, the Medicine Change Request Form must be faxed to Connection to Care.
 
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.
 
Zoloft (sertraline HCL)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Medicine Change Request Form
Download printable Form Connection to Care Program Overview
Download printable Form Pfizer Connection to Care Quick Reference Guide for HCPs
Download printable Form Connection to Care Application
Download printable Form Connection to Care Application-Spanish
(Requires Acrobat Reader
 
 
Pfizer Pfriends

PO Box 66543
St. Louis, MO 63166
Phone :
Fax: Not Applicable
Eligibility
> The patient must have been prescribed a Pfizer medicine, have no prescription insurance, and reside in the US, USVI, or Puerto Rico. There are no income requirements for the program.
Who Can Apply
> Anyone in need of assistance can call to apply, or can download an application online and sumit to the program.
Required
> The doctor needs to provide a prescription to the patient.The patient must either apply over the phone or submit an application form.
Supply
> Eligible patients will be sent a Pfizer Pfriends savings card that can be used at over 95% of pharmacies in the US. When filling their Pfizer prescription, patients simply present the Pfizer Pfriends card to their pharmacist to receive immediate savings.
Ship To
> Savings Card is shipped to the patient's home; medicine can be retreived with the savings card at the pharmacy.
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.
 
Zoloft (sertraline HCL)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Pfizer Pfriends Application
Download printable Form Pfizer Pfriends Application-Spanish
(Requires Acrobat Reader
 
 
Together Rx Access

PO Box 9426
Wilmington, DE 19809-9944
Phone : 800-444-4106
Fax:
Eligibility
> The patient must have no insurance and have an income at or below $30,000 for an individual ($60,000 for a family of four) The patient must also be a US resident.
Who Can Apply
> The patient can call to get an application, apply on line, or download the application.
Required
> Eligible people simply respond to four questions to enroll.
Supply
> Together Rx Access prescription savings card.
Ship To
> Patient's home
Note
> The patient can call to get an application, apply on line, or download the 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.
 
Zoloft (sertraline HCL)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Xubex Pharmaceutical Services

PO Box 1244
Winter Park, FL 32790-1244
Phone : 866-699-8239
Fax: 407-671-7960
Eligibility
> The patient must have an income at or below 243% of the Federal Poverty Level.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application.
Supply
>
Ship To
> Either Doctor's office or Patient's home
Note
> Anyone requesting assistance can call to request a faxed application or download it from the website.
 
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.
 
Zoloft (sertraline HCL)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader