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1 1. Eligibility 2 2. Prescriber Information 3 3. Prescription Coverage Information 4 4. Privacy Statement 5 5. Download Form
Step 1 of 5

Who Is This Form For?

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


Does your patient qualify to receive free medicine through the Pfizer Patient Assistance Program?

You should complete this form if your patient:

  • Has 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)
    • Toviaz® (fesoterodine fumarate)
    • Trecator® (ethionamide) tablets
    • Zarontin® (ethosuximide)
  • Lives in the United States or a US territory
  • Has no prescription coverage, or not enough coverage, to pay for their Pfizer medicine
  • Meets certain income limits (see chart below):
No. of people in your patient's 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 your patient lives in Alaska or Hawaii, or has 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 5

Who Is This Form For?

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


Does your patient qualify to receive free medicine through the Pfizer Patient Assistance Program?

You should complete this form if your patient:

  • Has been prescribed a Pfizer Group B medicine, including:
    • Rapamune® (sirolimus)
    • Rapamune® (sirolimus) oral suspension
    • Tygacil® (tigecycline) for injection
    • Vfend® (voriconazole)
  • Lives in the United States or a US territory
  • Has no prescription coverage, or not enough coverage, to pay for their Pfizer medicine
  • Meets certain income limits (see chart below):
No. of people in your patient's household Total monthly income before taxes Total annual income before taxes
Less Than or Equal to $4,253 Less Than or Equal to $51,040
Less Than or Equal to $5,747 Less Than or Equal to $68,960
Less Than or Equal to $7,240 Less Than or Equal to $86,880
Less Than or Equal to $8,733 Less Than or Equal to $104,800
Less Than or Equal to $10,227 Less Than or Equal to $122,720

If your patient lives in Alaska or Hawaii, or has 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 2020 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 5

Who Is This Form For?

This enrollment form is for Prescribers who have patients that 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.

Important: Due to pharmacy laws in Texas, which is where our new mail-order pharmacy operates, controlled substances - including Lyrica® and Lyrica® CR - can only be dispensed through our program if written by a Medical Doctor (MD) or Doctor of Osteopathy (DO). If you are not a MD or DO, please work with your supervising physician to complete the enrollment form and prescription requirements.


Does your patient qualify to receive free medicine through the
Pfizer Patient Assistance Program?

You should complete this enrollment form if you are a licensed Medical Doctor (MD) or Doctor of Osteopathy (DO) and your patient:

  • Has been prescribed LYRICA (pregabalin) or LYRICA CR (pregabalin) extended-release tablets CV
  • Lives in the United States or a US territory
  • Has no prescription coverage, or not enough coverage, to pay for
    their medicine
  • Meets certain income limits (see chart below):
No. of people in patient’s household Total monthly income before taxes Total annual income before taxes
Less Than or Equal to $4,253 Less Than or Equal to $51,040
Less Than or Equal to $5,747 Less Than or Equal to $68,960
Less Than or Equal to $7,240 Less Than or Equal to $86,880
Less Than or Equal to $8,733 Less Than or Equal to $104,800
Less Than or Equal to $10,227 Less Than or Equal to $122,720

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 2020 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.