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1 1. Eligibility 2 2. Vaccine Approval Number 3 3. Patient Information 4 4. Patient Privacy Statement 5 5. HIPAA Authorization Form 6 6. Prescriber Information 7 7. Vaccine Information 8 8. Prescriber Privacy Statement 9 9. Download Form
Step 1 of 9

Who Is This Form For?

This enrollment form is for Prescribers who have uninsured patients who need help paying for Prevnar 13® (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM 197 Protein]) and/or Trumenba® (Meningococcal Group B Vaccine). Through the Pfizer Patient Assistance Program, Prescribers' purchased stock of the vaccine is replenished when administered to eligible patients approved for assistance.


Does your patient qualify for vaccine replacement?

To be eligible for assistance, your patient must:

  • Have no insurance or prescription coverage for the vaccine needed
  • Reside in the United States
  • Meet certain age requirements:
    • Prevnar 13®: Be at least 18 years of age
    • Trumenba®: Be between 19 and 25 years of age
  • Meet 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.