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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.

One of these programs is the Pfizer Patient Assistance Program, which provides eligible patients with their Pfizer medicines for free.

If you are interested in applying to the Pfizer Patient Assistance Program, please follow the prompts below to tell us a little bit more about yourself. You will then be able to start filling out a program application online.

Please note: Filling out this form on the website does not complete a patient's enrollment. Once the forms are filled out, patients and their Prescribers must then print their respective portions and work together to ensure that a hard copy of the completed form and any other required documents are submitted to the program via mail or fax.
Information provided on this form will not be seen, stored, or transmitted to Pfizer until it's sent into the program via mail or fax.
If you do not see your medicine, please use our program finder to see what assistance programs may be available for the medicine you’ve been prescribed.
Complete enrollment form:

*Terms and conditions apply.

The Pfizer Savings Program is not health insurance. For more information, please 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.

Smart Form

E-mail
 
1 1. Eligibility 2 2. Patient Information 3 3. Prescription Coverage Information 4 4. Privacy Statement 5 5. HIPAA Authorization Form 6 6. 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
  • 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.

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)
    • Phospholine Iodide® (echothiophate iodide)
    • 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)
    • Skelaxin® (metaxalone)
    • Synarel® (nafarelin acetate)
    • Tikosyn® (dofetilide)
    • 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
    • Revatio® (sildenafil) tablets
    • Revatio® (sildenafil) 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 (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?


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

Smart Form Prescriber

E-mail
 
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)
    • Phospholine Iodide® (echothiophate iodide)
    • 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)
    • Skelaxin® (metaxalone)
    • Synarel® (nafarelin acetate)
    • Tikosyn® (dofetilide)
    • 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
    • Revatio® (sildenafil) tablets
    • Revatio® (sildenafil) 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 $4,163 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 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.


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

You should complete this enrollment form if 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 $4,163 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.

Smartform Group C

E-mail
 
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 $4,163 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.