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The document is an enrollment form for the Pfizer Patient Assistance Program, designed to help patients in the U.S. obtain certain Group A medicines for free. It outlines eligibility criteria, including lack of prescription coverage and income limits, and provides instructions on how to apply, including required documentation. The program aims to assist those who cannot afford their prescribed medications.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How much does Tikosyn cost without insurance?

The cost for Tikosyn 125 mcg oral capsule is around $710 for a supply of 60 capsules, depending on the pharmacy you visit. Quoted prices are for cash-paying customers and are not valid with insurance plans. This price guide is based on using the Drugs.com discount card which is accepted at most U.S. pharmacies.

What to do if a patient cannot afford medication?

Drug Assistance Programs. Many pharmaceutical companies, state programs, and nonprofits have patient assistance programs (PAPs) that can lower the cost of medicines if you dont have insurance or are underinsured and cant afford your medicine.

What is the income limit for Pfizer?

General FAQs Persons in family/householdPoverty guideline300% of the FPL 5 $36,580 $109,740 6 $41,960 $125,880 7 $47,340 $142,020 8 $52,720 $158,1604 more rows

How can I get my prescription if I cant afford it?

Reach out to your state Medicaid office for information about prescription payment help and drug discount programs that are available where you live. Medicare. If youre 65 or older, you can sign up for Medicare drug coverage (Part D) as a first step. Extra Help program. State pharmaceutical assistance programs.

What is the income limit for Novo Nordisk patient assistance?

Who is eligible for this program? Patients must be a US citizen or legal resident, must have a total household income at or below 400% of the federal poverty level, and must be uninsured or have Medicare.

pfizer patient assistance program application form

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Does Pfizer offer a patient assistance program?

For live support, call 1-877-744-5675 (MondayFriday 8 AM8 PM ET). The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation. Free medicines from Pfizer are provided through the Pfizer Patient Assistance Foundation.

Who is eligible for the patient assistance program?

Eligibility and enrollment Be a US citizen or legal resident. Have a total household income at or below 400% of the federal poverty level. Must be uninsured, or have Medicare. Note: if you have private or commercial insurance, you are not eligible for the PAP.

How do I get help paying for Tikosyn?

For help with the TIKOSYN $4 Co-pay Card, call 1-877-TIKOSYN (1-877-845-6796), or write: TIKOSYN Rebates, PO Box 4930, Warren, NJ 07059-6600.

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How much does Tikosyn cost without insurance?

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What is the income limit for Novo Nordisk patient assistance?

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