Download Applications

Pfizer RxPathways connects eligible patients to a range of assistance programs that offer insurance support, co-pay help, and medicines for free or at a savings.

Below are downloadable versions of our most frequently requested program application forms. These forms are designed for patients who want to apply to the Pfizer Patient Assistance Program to receive their medicines for free, or who need help understanding their insurance coverage.

The Pfizer medicines associated with these application forms are listed below with an "A,"B,"C," or "D" to their left to help you easily identify the application that’s right for you, based on the medicine you’ve been prescribed.

If you do not see your medicine listed below, please use our program finder to see what assistance programs may be available for the medicine you’ve been prescribed.
A
Arthrotec® (diclofenac sodium/misoprostol)
B
Aromasin® (exemestane tablets)
B
BeneFIX® (coagulation factor IX (recombinant))*
B
Bosulif® (bosutinib)*
A
Caduet® (amlodipine besylate/atorvastatin calcium)
B
Camptosar® (irinotecan HCl injection)
A
Caverject® (alprostadil for injection)
A
Celebrex® (celecoxib capsules)
A
Celontin® (methsuximide capsules)
A
Chantix® (varenicline)
A
Cleocin® (clindamycin)
A
Depo®-Estradiol (estradiol cypionate injection)
A
Depo-Provera® (medroxyprogesterone acetate injectable suspension)
A
Depo-subQ Provera 104® (medroxyprogesterone acetate injectable suspension 104 mg/0.65 mL)
A
Detrol® (tolterodine tartrate)
A
Dilantin® (phenytoin oral suspension, phenytoin, and extended phenytoin sodium)
A
Duavee® (conjugated estrogens/bazedoxifene)
A
Effexor XR® (venlafaxine hydrochloride)
B
Ellence® (epirubicin hydrochloride injection)
B
Emcyt® (estramustine phosphate sodium capsules)
A
Estring® (estradiol vaginal ring)
A
Feldene® (piroxicam)
A
Flector® Patch (diclofenac epolamine topical patch)
A
Fragmin® (dalteparin sodium) for Injection Rx
A
Glyset® (miglitol)
A
Heparin® (sodium injection)
B
Ibrance® (palbociclib)*
B
Idamycin PFS® (idarubicin hydrochloride for injection, USP)
B
Inlyta® (axitinib) tablets*
A
Inspra® (eplerenone)
A
Lincocin® (lincomycin)
D
Lyrica® (pregabalin) CV
A
Menest® (esterified estrogens)
A
Mycobutin® (rifabutin)
A
Nicotrol® (nicotine)
A
Nitrostat® (nitroglycerin)
A
Norpace® (disopyramide phosphate)
A
Phospholine Iodide® (echothiophate iodide) for Ophthalmic Solution Bottle Rx
A
Premarin® (conjugated estrogens)
A
Premarin® (conjugated estrogens) Vaginal Cream
A
Premphase® (conjugated estrogens plus medroxyprogesterone acetate tablets)
A
Prempro® (conjugated estrogens/medroxyprogesterone acetate) tablets
C
Prevnar 13® (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]).
A
Pristiq® (desvenlafaxine)
A
Procardia® XL (nifedipine)
A
QuilliChew ER® (methylphenidate hydrochloride)
A
Quillivant XR® (methylphenidate hydrochloride) CII
B
Rapamune® (sirolimus)
A
Relpax® (eletriptan HBr)
B
Revatio® (sildenafil) tablets
A
Skelaxin® (metaxalone)
B
Sutent® (sunitinib malate)*
A
Synarel® (nafarelin acetate)
A
Tikosyn® (dofetilide)
B
Torisel® (temsirolimus) injection*
A
Toviaz® (fesoterodine fumarate)
A
Trecator® (ethionamide tablets)
B
Tygacil® (tigecycline) for injection*
B
Vfend® (voriconazole)
A
Viagra® (sildenafil citrate) tablets
B
Xalkori® (crizotinib)*
B
Xyntha® (antihemophilic factor (recombinant) plasma/albumin-free)*
A
Zarontin® (ethosuximide)
B
Zinecard® (dexrazoxane for injection)

*Pfizer Insurance Support available.

Terms and conditions apply.

The Pfizer Savings Program is not health insurance. For a complete list of participating pharmacies, click here or call the toll-free number 1-866-706-2400. There are no membership fees to participate in this program. Estimated savings range from 36% to 75% and depend on such factors as the particular drug purchased, amount purchased, and the pharmacy where purchased.