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Program Details

PFIZER, INC.
Pfizer Bridge Program
Somavert (pegvisomant)
 
CONTACT INFO
Address:
,
Phone: 1-800-645-1280 Provider Phone:
Fax: 1-800-479-2562 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Determined on case-by-case basis, call for prescreening.
  • Patients with Medicare Part D may be eligible, contact program for details.
    • Income at or below: Single 500 % FPL
      Couple 500 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Not Published
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Not Published
    Physician License #
    Required:    		 Not Published
    Prescriber Signature
    Allowed:    		 Physician
    Application may be
    faxed:    		 Yes
    Eligibility determination
    letter sent:    		 Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: Varies
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Program will contact patient
    Other Information: Applications cannot be downloaded from the product sites. The physician can call the Pfizer Bridge Program at (800) 645-1280 to initiate the reimbursement and/or patient assistance process.

    Last Updated: 12/15/2023

    		  

     

     


    Application Forms
    & Instructions
    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)

     

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