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Program Details
PFIZER, INC.
Pfizer Patient Assistance Program
Flector Patch 1.3%
(diclofenac epolamine topical patch)
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| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-866-706-2400 |
Provider Phone: |
|
| Fax: |
1-866-470-1748 |
Website: |
Program Website |
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| ELIGIBILITY
|
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| Eligibility
Info: |
To apply, please visit the program interactive forms at: Pfizer RxPathways
The Pfizer Patient Assistance Program provides eligible patients with select Pfizer medicines for free. To qualify:
Note: Commercially insured patients are not eligible for the PAP, regardless of their income status or medicine's formulary status.
Patients must meet program income guidelines, which vary by product and household size.
Medicines accessed through the PAP must be for an FDA approved indication.
Patients must reside in the US or any of the US territories.
|
| Income at or below: |
Not
Published |
| Other Income
Requirements: |
Income varies by medication needed.
Adjusted for family size.
NOTE: If patient has no income and does not file taxes, a letter from the physician stating the patient has no income OR a notarized letter from a family member is required. |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
No |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
Either DEA or State
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
90 days
|
| Delivery Time: |
2-4 weeks
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
Varies |
| Other Information: |
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Last Updated: 12/15/2023
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Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
Medication List
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