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1 1. Eligibility 2 2. Patient Information 3 3. Prescription Coverage Information 4 4. Privacy Statement 5 5. Patient Authorization for Electronic Income Verification 6 6. HIPAA Authorization Form 7 7. Download Form
STEP 1 of 6

Who Is This Form For?

This enrollment form is for patients who would like to apply to receive LYRICA® (pregabalin) CV or LYRICA® CR (pregabalin) extended-release tablets CV for free through the Pfizer Patient Assistance Program.


Do I qualify to receive free medicine through the Pfizer Patient Assistance Program?

You should complete this enrollment form if you:

  • Have been prescribed LYRICA (pregabalin) or LYRICA CR (pregabalin) extended-release tablets CV by a licensed Medical Doctor (MD) or Doctor of Osteopathy (DO)
  • Live in the United States or a US territory
  • Have no prescription coverage, or not enough coverage, to pay for your medicine

If you need immediate assistance with your Group D medicine, please call 1-866-706-2400.

The Pfizer Patient Assistance Program is a joint program of Pfizer Inc., and the Pfizer Patient Assistance FoundationTM.

The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions.

STEP 1 of 6

Who Is This Form For?

This enrollment form is for patients who would like to apply to receive any of the Group A medicines listed below for free through the Pfizer Patient Assistance Program.


Do I qualify to receive free medicine through the Pfizer Patient Assistance Program?

You should complete this form if you:

 

  • Have been prescribed a Pfizer Group A medicine, including:
    • Arthrotec® (diclofenac sodium/misoprostol)
    • Caduet® (amlodipine besylate/atorvastatin calcium)
    • Caverject® (alprostadil) for injection
    • Celebrex® (celecoxib) capsules
    • Celontin® (methsuximide) capsules
    • Chantix® (varenicline)
    • Cleocin® (clindamycin)
    • Depo®-Estradiol (estradiol cypionate) injection
    • Depo-Provera® (medroxyprogesterone acetate) injectable suspension
    • Depo-subQ Provera 104® (medroxyprogesterone acetate) injectable suspension 104 mg/0.65 mL
    • Detrol® (tolterodine tartrate)
    • Detrol®LA (tolterodine tartrate) extended release capsules
    • Dilantin® (phenytoin oral suspension, phenytoin, and extended phenytoin sodium)
    • Duavee® (conjugated estrogens/bazedoxifene)
    • Estring® (estradiol vaginal ring)
    • Feldene® (piroxicam)
    • Flector®Patch (diclofenac epolamine) topical patch
    • Fragmin® (dalteparin sodium)
    • Glyset® (miglitol)
    • Heparin® sodium injection
    • Inspra® (eplerenone)
    • Lincocin® (lincomycin)
    • Menest® (esterified estrogens)
    • Mycobutin® (rifabutin)
    • Nicotrol® (nicotine)
    • Norpace® (disopyramide phosphate)
    • Premarin® (conjugated estrogens)
    • Premarin® (conjugated estrogens) vaginal cream
    • Premphase® (conjugated estrogens plus medroxyprogesterone acetate) tablets
    • Prempro® (conjugated estrogens/ medroxyprogesterone acetate) tablets
    • Pristiq® (desvenlafaxine)
    • Relpax® (eletriptan HBr)
    • Synarel® (nafarelin acetate)
    • Tikosyn® (dofetilide) capsules
    • Toviaz® (fesoterodine fumarate)
    • Trecator® (ethionamide) tablets
    • Zarontin® (ethosuximide)
  • Live in the United States or a US territory
  • Have no prescription coverage, or not enough coverage, to pay for your Pfizer medicine
  • Meet certain income limits (see chart below):
No. of people in your household Total monthly income before taxes Total annual income before taxes
Less Than or Equal to $4,163 Less Than or Equal to $49,960
Less Than or Equal to $5,637 Less Than or Equal to $67,640
Less Than or Equal to $7,110 Less Than or Equal to $85,320
Less Than or Equal to $8,583 Less Than or Equal to $103,000
Less Than or Equal to $10,057 Less Than or Equal to $120,680

If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 1-866-706-2400.

Note: Income limits are subject to change on an annual basis; current limits reflect 2019 Federal Poverty Level Guidelines.

The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance FoundationTM. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions.

STEP 1 of 6

Who Is This Form For?

This enrollment form is for patients who would like to apply to receive any of the Group B medicines listed below for free through the Pfizer Patient Assistance Program.


Do I qualify to receive free medicine through the Pfizer Patient Assistance Program?

You should complete this form if you:

  • Have been prescribed a Pfizer Group B medicine, including:
    • Rapamune® (sirolimus)
    • Rapamune® (sirolimus) oral suspension
    • Tygacil® (tigecycline) for injection
    • Vfend® (voriconazole)
  • Live in the United States or a US territory
  • Have no prescription coverage, or not enough coverage, to pay for your medicine
  • Meet certain income limits (income limit is 400% of the federal poverty level)

If you need immediate assistance with your Group B medicine, please call 1-855-239-9869

The Pfizer Patient Assistance Program is a joint program of Pfizer Inc., and the Pfizer Patient Assistance FoundationTM. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions.

STEP 1 of 6

Who Is This Form For?


Do I qualify to receive free medicine through the Pfizer Patient Assistance Program?

You should complete this enrollment form if you:

  • Have been prescribed LYRICA (pregabalin) or LYRICA CR (pregabalin) extended-release tablets CV
  • Live in the United States or a US territory
  • Have no prescription coverage, or not enough coverage, to pay for your medicine
  • Meet certain income limits (see chart below):
No. of people in your household Total monthly income before taxes Total annual income before taxes
Less Than or Equal to $4,163 Less Than or Equal to $49,960
Less Than or Equal to $5,637 Less Than or Equal to $67,640
Less Than or Equal to $7,110 Less Than or Equal to $85,320
Less Than or Equal to $8,583 Less Than or Equal to $103,000
Less Than or Equal to $10,057 Less Than or Equal to $120,680

If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 866-706-2400.

Note: Income limits are subject to change on an annual basis: current limits reflect 2019 Federal Poverty Level Guidelines.

The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance FoundationTM.

Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc. with distinct legal restrictions