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START ENROLLMENT
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 ) 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 MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER PATIENT ASSISTANCE PROGRAM HIPAA Authorization Form for the Disclosure of Patient Information FOR PFIZER INC. AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC. PFIZERASSISTANCE PROGRAMS
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. FIND PRESCRIPTION ASSISTANCE Pfizer PAP Connect: Online access to the Pfizer Patient Assistance Program . Pfizer PAP Connect is a new tool that provides patients and their healthcare providers with online access to the Pfizer Patient Assistance Program, enabling them to place medicine orders, track shipments, and manage their enrollment for certain primary care medicines in real time, at any time.START ENROLLMENT
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 ) 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 MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER PATIENT ASSISTANCE PROGRAM HIPAA Authorization Form for the Disclosure of Patient Information FOR PFIZER INC. AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC. PFIZERASSISTANCE PROGRAMS
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. LEARN ABOUT PROGRAMS Pfizer RxPathways provides access to co-pay and savings offers for many brand-name medicines. Learn more about the Pfizer RxPathways prescription program, and find out if you are eligible. CO-PAY AND SAVINGS OFFERS* To help eligible patients save, Pfizer provides access to co-pay and savings offers for a variety of brand-name medicines, regardless of apatient’s income.
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER COMPASSIONATE USE AND EXPANDED ACCESS FOR The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation™. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions. PFIZER PATIENT ASSISTANCE PROGRAM HIPAA Authorization Form for the Disclosure of Patient Information FOR PFIZER INC. AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC. PFIZERASSISTANCE PROGRAMS
PFIZER RXPATHWAYS PATIENT ASSISTANCE PROGRAM PRX717902 2 015 Pfizer Inc. Printed in USA/January 2015 FRMRXP101 HELP PAYING FOR PRESCRIPTION MEDICINE • Veterans Affairs . www.va.gov If you are a veteran and need help paying for your medicines, Veterans Affairs will you get them. With veteran’s benefits, you may be CONOZCA LOS PROGRAMAS La Herramienta de asistencia para medicinas (MAT, por sus siglas en inglés) es un motor de búsqueda basado en la Web que conecta a pacientes, sus cuidadores de salud, y sus proveedores de cuidado de salud a más de 200 programas de apoyo y asistencia financiera, ambos privados y públicos, que pueden ayudar a pacientes que cumplen con los requisitos para encontrar apoyo financiero debido a MEDICINE ASSISTANCE TOOL (MAT) La Herramienta de asistencia para medicinas (MAT, por sus siglas en inglés) es un motor de búsqueda basado en la Web que conecta a pacientes, sus cuidadores de salud, y sus proveedores de cuidado de salud a más de 200 programas de apoyo y asistencia financiera, ambos privados y públicos, que pueden ayudar a pacientes que cumplen con los requisitos para encontrar apoyo financiero debido a FIND PRESCRIPTION ASSISTANCE Find Assistance That's Right for You. 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. †. Enter the name of the medicine you've been prescribed. You can search one medicine at a time. Then answer a few questions tosee which
START ENROLLMENT
Start Enrollment. 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 MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. PFIZER PATIENT ASSISTANCE PROGRAM HIPAA Authorization Form for the Disclosure of Patient Information FOR PFIZER INC. AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC. PFIZERASSISTANCE PROGRAMS
FIND PRESCRIPTION ASSISTANCE Find Assistance That's Right for You. 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. †. Enter the name of the medicine you've been prescribed. You can search one medicine at a time. Then answer a few questions tosee which
START ENROLLMENT
Start Enrollment. 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 MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. PFIZER PATIENT ASSISTANCE PROGRAM HIPAA Authorization Form for the Disclosure of Patient Information FOR PFIZER INC. AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC. PFIZERASSISTANCE PROGRAMS
LEARN ABOUT PROGRAMS Pfizer RxPathways provides access to co-pay and savings offers for many brand-name medicines. Learn more about the Pfizer RxPathways prescription program, and find out if you are eligible. CO-PAY AND SAVINGS OFFERS* Cards will be accepted only at participating pharmacies. Cards are not health insurance. No membership fees. Maximum annual savings of $15 to $25,000. For more information, call 1-866-341-9100 or write to Pfizer, PO Box 29387, Mission, KS 66201. MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER COMPASSIONATE USE AND EXPANDED ACCESS FOR The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation™. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions. PFIZER PATIENT ASSISTANCE PROGRAM HIPAA Authorization Form for the Disclosure of Patient Information FOR PFIZER INC. AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC. PFIZERASSISTANCE PROGRAMS
PFIZER RXPATHWAYS PATIENT ASSISTANCE PROGRAM PRX717902 2 015 Pfizer Inc. Printed in USA/January 2015 FRMRXP101 HELP PAYING FOR PRESCRIPTION MEDICINE • Veterans Affairs . www.va.gov If you are a veteran and need help paying for your medicines, Veterans Affairs will you get them. With veteran’s benefits, you may be CONOZCA LOS PROGRAMAS Desde el apoyo con el seguro y la ayuda con el copago*, a medicinas gratuitas o con descuento, † Pfizer RxPathways conecta a pacientes con una variedad de programas y recursos que los pueden ayudarlos a obtener las medicinas de Pfizer que necesitan. Programa de Ayuda alPaciente de Pfizer.
MEDICINE ASSISTANCE TOOL (MAT) La Herramienta de asistencia para medicinas (MAT, por sus siglas en inglés) es un motor de búsqueda basado en la Web que conecta a pacientes, sus cuidadores de salud, y sus proveedores de cuidado de salud a más de 200 programas de apoyo y asistencia financiera, ambos privados y públicos, que pueden ayudar a pacientes que cumplen con los requisitos para encontrar apoyo financiero debido a FIND PRESCRIPTION ASSISTANCE Find Assistance That's Right for You. 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. †. Enter the name of the medicine you've been prescribed. You can search one medicine at a time. Then answer a few questions tosee which
START ENROLLMENT
Start Enrollment. 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 PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER RXPATHWAYS PATIENT ASSISTANCE PROGRAM: ENROLLMENT Pfizer RxPathways Patient Assistance Program: EnrollmEnt Form For GrouP B mEdicinEs do i Qualify For Free medicine through Pfizer RxPathways? You are eligible for free medicine and should complete this enrollment form if you: PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. FIND PRESCRIPTION ASSISTANCE Find Assistance That's Right for You. 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. †. Enter the name of the medicine you've been prescribed. You can search one medicine at a time. Then answer a few questions tosee which
START ENROLLMENT
Start Enrollment. 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 PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER RXPATHWAYS PATIENT ASSISTANCE PROGRAM: ENROLLMENT Pfizer RxPathways Patient Assistance Program: EnrollmEnt Form For GrouP B mEdicinEs do i Qualify For Free medicine through Pfizer RxPathways? You are eligible for free medicine and should complete this enrollment form if you: PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. LEARN ABOUT PROGRAMS Pfizer RxPathways provides access to co-pay and savings offers for many brand-name medicines. Learn more about the Pfizer RxPathways prescription program, and find out if you are eligible. CO-PAY AND SAVINGS OFFERS* Cards will be accepted only at participating pharmacies. Cards are not health insurance. No membership fees. Maximum annual savings of $15 to $25,000. For more information, call 1-866-341-9100 or write to Pfizer, PO Box 29387, Mission, KS 66201. MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER COMPASSIONATE USE AND EXPANDED ACCESS FOR The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation™. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions. PFIZER PATIENT ASSISTANCE PROGRAM HIPAA Authorization Form for the Disclosure of Patient Information FOR PFIZER INC. AND THE PFIZER PATIENT ASSISTANCE FOUNDATION, INC. PFIZERASSISTANCE PROGRAMS
PFIZER RXPATHWAYS PATIENT ASSISTANCE PROGRAM PRX717902 2 015 Pfizer Inc. Printed in USA/January 2015 FRMRXP101 HELP PAYING FOR PRESCRIPTION MEDICINE • Veterans Affairs . www.va.gov If you are a veteran and need help paying for your medicines, Veterans Affairs will you get them. With veteran’s benefits, you may be CONOZCA LOS PROGRAMAS La Herramienta de asistencia para medicinas (MAT, por sus siglas en inglés) es un motor de búsqueda basado en la Web que conecta a pacientes, sus cuidadores de salud, y sus proveedores de cuidado de salud a más de 200 programas de apoyo y asistencia financiera, ambos privados y públicos, que pueden ayudar a pacientes que cumplen con los requisitos para encontrar apoyo financiero debido a MEDICINE ASSISTANCE TOOL (MAT) La Herramienta de asistencia para medicinas (MAT, por sus siglas en inglés) es un motor de búsqueda basado en la Web que conecta a pacientes, sus cuidadores de salud, y sus proveedores de cuidado de salud a más de 200 programas de apoyo y asistencia financiera, ambos privados y públicos, que pueden ayudar a pacientes que cumplen con los requisitos para encontrar apoyo financiero debido a FIND PRESCRIPTION ASSISTANCE Find Assistance That's Right for You. 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. †. Enter the name of the medicine you've been prescribed. You can search one medicine at a time. Then answer a few questions tosee which
START ENROLLMENT
Start Enrollment. 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 LEARN ABOUT PROGRAMS Pfizer RxPathways provides access to co-pay and savings offers for many brand-name medicines. Learn more about the Pfizer RxPathways prescription program, and find out if you are eligible. MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. INICIAR INSCRIPCIÓN Iniciar inscripción. Pfizer RxPathways une a pacientes que cumplan con los requisitos con una variedad de programas de asistencia que brindan apoyo con seguros, ayuda con copagos* y medicamentos, de forma gratuita o a precios reducidos. †. Uno de estos programas es el Pfizer Patient Assistance Program, que proporciona de forma gratuita a CONOZCA LOS PROGRAMAS Desde el apoyo con el seguro y la ayuda con el copago*, a medicinas gratuitas o con descuento, † Pfizer RxPathways conecta a pacientes con una variedad de programas y recursos que los pueden ayudarlos a obtener las medicinas de Pfizer que necesitan. Programa de Ayuda alPaciente de Pfizer.
FIND PRESCRIPTION ASSISTANCE Find Assistance That's Right for You. 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. †. Enter the name of the medicine you've been prescribed. You can search one medicine at a time. Then answer a few questions tosee which
START ENROLLMENT
Start Enrollment. 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 LEARN ABOUT PROGRAMS Pfizer RxPathways provides access to co-pay and savings offers for many brand-name medicines. Learn more about the Pfizer RxPathways prescription program, and find out if you are eligible. MEDICINE ASSISTANCE TOOL (MAT) Medicine Assistance Tool (MAT) is a web-based search engine that connects patients, their caregivers, and their healthcare providers to more than 200 private and public financial support and assistance programs that can help eligible patients find financial support due to their lack of insurance or inadequate prescription medicine coverage. PFIZER PATIENT ASSISTANCE PROGRAM patient assistance program. PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. P A photocopy of one of the following documents that shows your total annual income: • Pages 1 & 2 of the previous year’s federal tax return (form 1040 or 1040EZ) PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
PFIZER PATIENT ASSISTANCE PROGRAM P Gather the following required documents: P Completed and signed enrollment form (pages 3-4) Note: Please do not send in the Instructions, and please retain the HIPAA form for your own records. • If you are currently enrolled and you are applying for re-enrollment, please include your Patient ID on Page 3. INICIAR INSCRIPCIÓN Iniciar inscripción. Pfizer RxPathways une a pacientes que cumplan con los requisitos con una variedad de programas de asistencia que brindan apoyo con seguros, ayuda con copagos* y medicamentos, de forma gratuita o a precios reducidos. †. Uno de estos programas es el Pfizer Patient Assistance Program, que proporciona de forma gratuita a CONOZCA LOS PROGRAMAS Desde el apoyo con el seguro y la ayuda con el copago*, a medicinas gratuitas o con descuento, † Pfizer RxPathways conecta a pacientes con una variedad de programas y recursos que los pueden ayudarlos a obtener las medicinas de Pfizer que necesitan. Programa de Ayuda alPaciente de Pfizer.
SEE OUR IMPACT
See Our Impact. In 2020, Pfizer helped more than 136,000 patients receive over 850,000 Pfizer prescriptions for free or at a savings.*. Pfizer helps patients save on approximately 116 Pfizer medicines through the Pfizer Savings Program. †. View list of available medicines. Pfizer provides more than 60 medicines for free through thePfizer
MEDICINES FOR FREE MEDICINES AT A SAVINGS 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 the Pfizer medicines available to eligible patients through two of these programs, the Pfizer Patient Assistance Program and the Pfizer Savings Program. To learn more about Pfizer’s assistance programs — or to be PFIZER PATIENT ASSISTANCE PROGRAM If you live in Alaska or Hawaii, or have a household of greater than 5 members, please call 855-239-9869. Note: Income limits are subject tochange on an annual
FIND PRESCRIPTION ASSISTANCE 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. THE PFIZER INSTITUTIONAL PATIENT ASSISTANCE PROGRAM (IPAP Our Reach: • Who we are: The Pfizer IPAP helps eligible uninsured patients receive free Pfizer medicines through select health centers, free clinics, and hospitals across the country. • Who we help: Patients are eligible to receive Pfizer medicine through the Pfizer IPAP if they § Are a registered outpatient of an IPAP-participatingfacility.
PFIZER RXPATHWAYS PATIENT ASSISTANCE PROGRAM: ENROLLMENT Pfizer RxPathways Patient Assistance Program: EnrollmEnt Form For GrouP B mEdicinEs do i Qualify For Free medicine through Pfizer RxPathways? You are eligible for free medicine and should complete this enrollment form if you: MEDICINE ASSISTANCE TOOL (MAT) You are now leaving Pfizer RxPathways. Links to other sites are provided as a convenience, and Pfizer does not take responsibility for the content of linked sites. Continue. For additional support, call 1-844-989-PATH (7284) 1-844-989-PATH (7284) for New Patients.1-866-706-2400.
PFIZER RXPATHWAYS PATIENT ASSISTANCE PROGRAM PRX717902 2 015 Pfizer Inc. Printed in USA/January 2015 FRMRXP101 HELP PAYING FOR PRESCRIPTION MEDICINE • Veterans Affairs . www.va.gov If you are a veteran and need help paying for your medicines, Veterans Affairs will you get them. With veteran’s benefits, you may be CONOZCA LOS PROGRAMAS La Herramienta de asistencia para medicinas (MAT, por sus siglas en inglés) es un motor de búsqueda basado en la Web que conecta a pacientes, sus cuidadores de salud, y sus proveedores de cuidado de salud a más de 200 programas de apoyo y asistencia financiera, ambos privados y públicos, que pueden ayudar a pacientes que cumplen con los requisitos para encontrar apoyo financiero debido a Pfizer recognizes the public concern in relation to COVID-19, which continues to evolve. Click here to learn how weare responding.
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* New patients Nuevos pacientes 1-844-989-PATH (7284) FIND ASSISTANCE THAT'S RIGHT FOR YOU FIND ASSISTANCE THAT'S RIGHT FOR YOU 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. Enter the name of the medicine you've been prescribed. You can search one medicine at a time. Then answer a few questions to see which available program(s) may be right for you.Search by medicine
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* ACCUPRIL®(quinapril hydrochloride) tablets * ACCURETIC™(quinapril HCl/hydrochlorothiazide) tablets * ALDACTAZIDE®(spironolactone/hydrochlorothiazide) * ALDACTONE®(spironolactone) tablets * ALTACE®(ramipril) * AROMASIN®(exemestane) tablets * ARTHROTEC®(diclofenac sodium/misoprostol) tablets * ATGAM® (lymphocyte immune globulin, anti-thymocyte globulinsterile solution)
* AZULFIDINE®(sulfasalazine) tablets, USP * BACITRACINfor Injection, USP * BAVENCIO®(avelumab) injection * BeneFIX®Coagulation Factor IX (Recombinant) * BESPONSA™ (inotuzumab ozogamicin, for injection, for intravenoususe)
* BOSULIF®(bosutinib) tablets * BRAFTOVI®(encorafenib) capsules * CADUET®(amlodipine besylate/atorvastatin calcium) tablets * CALAN®(verapamil hydrochloride) tablets * CAMPTOSAR®(irinotecan hydrochloride) injection * CARDURA®(doxazosin mesylate) tablets * CAVERJECT®(alprostadil) for injection * CELEBREX®(celecoxib) capsules * CELONTIN®(methsuximide) capsules, USP * CHANTIX®(varenicline) tablets * CLEOCIN®(clindamycin) * COLESTID® (micronized colestipol hydrochloride) * CORTEF® (hydrocortisone tablets) * CORVERT®(ibutilide fumarate) injection * CUTAQUIG®(Immune Globulin Subcutaneous (Human) - hipp) * CYKLOKAPRON® (tranexamic acid) injection * CYTOMEL®(liothyronine sodium) tablets * CYTOTEC®(misoprostol) tablets * DAURISMO™(glasdegib) tablets * DAYPRO®(oxaprozin) * DEPO-MEDROL® (methylprednisolone acetate injectable suspension) * DEPO-PROVERA® (medroxyprogesterone acetate injectable suspension) * DEPO-SUBQ PROVERA 104®(medroxyprogesterone acetate) injectablesuspension
* DEPO®-ESTRADIOL(estradiol cypionate) injection, USP * DEPO®-TESTOSTERONECIII (testosterone cypionate) injection, USP * DETROL®(tolterodine tartrate) tablets * DETROL® LA(tolterodine tartrate) extended-release capsules * DIFLUCAN® (fluconazole) * DILANTIN®(extended phenytoin sodium) capsules * DUAVEE™(conjugated estrogens/bazedoxifene) tablets * EFFEXOR XR®(venlafaxine HCl) extended-release capsules * ELELYSO™(taliglucerase alfa) for injection * ELIQUIS®(apixaban) tablets * ELLENCE®(epirubicin hydrochloride) injection * EMCYT®(estramustine phosphate sodium) capsules * ERAXIS™(anidulafungin) for injection * ESTRING®(estradiol vaginal ring) * EUCRISA®(crisaborole) ointment, 2% * FELDENE®(piroxicam) capsules * FLAGYL®(metronidazole) tablets * FLECTOR® Patch(diclofenac epolamine topical patch) 1.3% * FRAGMIN®(dalteparin sodium) injection * GENOTROPIN®(somatropin) for injection * GEODON®(ziprasidone HCl) * GLUCOTROL®(glipizide) tablets * GLYNASE® PRESTAB®(micronized glyburide) * GLYSET®(miglitol) tablets * HALCION®(triazolam) tablets, USP CIV * HEMABATE®(carboprost tromethamine) injection, USP * HEPARINSodium Injection, USP * IBRANCE®(palbociclib) capsules * IDAMYCIN PFS®(idarubicin hydrochloride) injection * INFLECTRA®(infliximab-dyyb) for injection * INLYTA®(axitinib) tablets * INSPRA®(eplerenone) tablets * LEVOXYL®(levothyroxine sodium) tablets * LINCOCIN®(lincomycin) injection, USP * LIPITOR®(atorvastatin calcium) tablets * LOMOTIL® (diphenoxylate hydrochloride/atropine sulfate) * LOPID®(gemfibrozil) tablets, USP * LORBRENA®(lorlatinib) tablets * LYRICA®(pregabalin) Capsules CV * LYRICA® CR(pregabalin) extended-release tablets * MEDROL®(methylprednisolone) tablets, USP * MEKTOVI®(binimetinib) tablets * MENEST®(esterified estrogens) tablets, USP * MYCOBUTIN®(rifabutin) capsules, USP * MYLOTARG™(gemtuzumab ozogamicin) for injection * NARDIL®(phenelzine sulfate) tablets, USP * NEURONTIN®(gabapentin) * NICOTROL®(nicotine) * NITROSTAT®(nitroglycerin) sublingual tablet * NIVESTYM®(filgrastim-aafi) injection * NORPACE®(disopyramide phosphate) * NORVASC®(amlodipine besylate) tablets * PANZYGA®(immune globulin intravenous, human - ifas) * PFIZERPEN®(penicillin G potassium) for injection * PREMARIN®(conjugated estrogens) tablets, USP * PREMARIN®(conjugated estrogens) Vaginal Cream * PREMPHASE®(conjugated estrogens plus medroxyprogesterone acetate)tablets
* PREMPRO®(conjugated estrogens/medroxyprogesterone acetate)tablets
* PREVNAR 13®(Pneumococcal 13-valent Conjugate Vaccine ) * PRISTIQ®(desvenlafaxine) extended-release tablets * PROCARDIA®(nifedipine) * PROCARDIA® XL(nifedipine) * PROTONIX®(pantoprazole sodium) * PROVERA®(medroxyprogesterone acetate) tablet, USP * R-GENE® 10Arginine Hydrochloride Injection, USP * RAPAMUNE®(sirolimus) * RAPAMUNE®(sirolimus) oral suspension * RELPAX®(eletriptan hydrobromide) tablets * RETACRIT®(epoetin alfa-epbx) injection * REVATIO®(sildenafil) oral suspension * REVATIO®(sildenafil) tablets * RUXIENCE™(rituximab-pvvr) injection * SOMAVERT®(pegvisomant) for injection * SONATA®(zaleplon) Capsules CIV * SUTENT®(sunitinib malate) capsules * SYNAREL®(nafarelin acetate) nasal solution * TALZENNA®(talazoparib) capsules * TESSALON®(benzonatate) capsules, USP * TORISEL®(temsirolimus) injection * TOVIAZ®(fesoterodine fumarate) extended-release tablets * TRAZIMERA™(trastuzumab-qyyp) for injection * TRECATOR®(ethionamide) tablets * TRUMENBA®(Meningococcal Group B Vaccine) * TYGACIL®(tigecycline) for injection * VFEND®(voriconazole) * VIAGRA®(sildenafil citrate) tablets * VISTARIL®(hydroxyzine pamoate) * VIZIMPRO®(dacomitinib) tablets * VYNDAMAX® (tafamidis) capsules * VYNDAQEL®(tafamidis meglumine) capsules * XALATAN®(latanoprost ophthalmic solution) 0.005% * XALKORI®(crizotinib) capsules * XANAX®CIV (alprazolam) tablets * XELJANZ®(tofacitinib) tablets * XELJANZ® XR(tofacitinib) extended-release tablets * XYNTHA®Antihemophilic Factor (Recombinant) * ZARONTIN®(ethosuximide) * ZINECARD®(dexrazoxane) for injection * ZIRABEV™(bevacizumab-bvzr) injection * ZITHROMAX®(azithromycin for injection) for IV infusion only * ZMAX®(azithromycin) extended-release for oral suspension * ZOLOFT®(sertraline hydrochloride) * ZYVOX®(linezolid) * No matching entries Answer 3 questions to find out which program(s) may be right for you. What type of prescription coverage do you have?close
Prescription Coverage MEDICARE/MEDICAID/VA Government-provided insurance, including Medicare, Medicaid, or insurance provided by the Department of Veterans Affairs. EMPLOYER-PROVIDED OR PURCHASED THROUGH A HEALTH INSURANCE MARKETPLACE Insurance provided by your employer or purchased through a health insurance marketplace. Also called an exchange, a health insurance marketplace is a resource where individuals, families, and small businesses can learn about their health coverage options, choose a plan, and enroll in coverage.OTHER
Your insurance is not covered in the 2 options above.NONE
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Select onePublic: Medicare/Medicaid/VAPrivate: Employer-provided or purchased through a health insurance marketplaceOtherNoneSelect one
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Household income is the total amount of money earned by the members of your household. If you're married and live with your spouse, you must include both incomes and any other income earned by dependents (a person other than you or your spouse who you claim as a tax exemption) living with you. “Before taxes” refers to gross income, the amount of money you have earned before taking out taxes. Yearly household income Yearly household incomeMonthly household income Yearly household income * Yearly household income * Monthly household income Find available programs Leave this field blank I can't find my medicine.Play Video
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This is a modal window. This modal can be closed by pressing the Escape key or activating the close button. WE'VE GOT YOU COVERED In this video, you'll learn how our specialized Medicine Access Counselors and resource-filled website can help connect you to the Pfizer medicine you need.Watch now
NEED HELP FINDING A PFIZER ASSISTANCE PROGRAM? We can show you the way. You can get information on all available programs right here, no matter what Pfizer medicine you're prescribed.Learn more
PFIZER PAP CONNECT: ONLINE ACCESS TO THE _PFIZER PATIENT ASSISTANCEPROGRAM_
Pfizer PAP Connect is a new tool that provides patients and their healthcare providers with online access to the _Pfizer Patient Assistance Program_, enabling them to place medicine orders, track shipments, and manage their enrollment for certain primary care medicines in real time, at any time.Start enrollment
PFIZER RXPATHWAYS: YOUR PATH TO PATIENT ASSISTANCE Meet Nelly, a community health worker that helps the Latino community gain access to Pfizer medicines.Watch now
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This is a modal window. This modal can be closed by pressing the Escape key or activating the close button. *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. You are now leaving Pfizer RxPathways.Continue
You are now leaving Pfizer RxPathways. Links to other sites are provided as a convenience, and Pfizer does not take responsibility for the content of linked sites.Continue
For additional support, call 1-844-989-PATH (7284)1-844-989-PATH (7284) for New Patients 1-866-706-2400 1-866-706-2400 for Enrolled PAP PatientsContact Pfizer
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The Pfizer Patient Assistance Program is a joint program of Pfizer Inc., and the Pfizer Patient Assistance Foundation™. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions. Pfizer RxPathways is part of Pfizer’s Global Social Investments portfolio. For more information, please visit www.pfizer.com/purpose.
The information provided in this site is intended only for residents of the United States. The products discussed herein may have different product labeling in different countries. 2020 Pfizer Inc. All rights reserved.PP-PAT-USA-1190
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