Copy of signed federal tax return from most recent tax year (pages 1 & 2 only) In the rare case that you are unable to provide a federal tax return from most recent year, we can consider alternate documents to verify your income. Physician Form, completed and signed by your treating physician 3. Once signed up for the co-pay portal, users may enroll, submit claims, and see claim and payment status. Required Documentation: In order to make a final eligibility determination on your application, the following information is all that you need: 1. The Pfizer Co-Pay Portal will allow healthcare providers, specialty pharmacies, and patients to register and enroll eligible patients in the Pfizer co-pay assistance programs for the products below. The program continues to provide personalized assistance through a dedicated professional representative, by phone, who will guide them through the application process and answer any questions you may have. The program offers online service for patients, providers and pharmacies allowing them to apply electronically through a secured, web-based application portal available 24 hours a day. Patient will be informed immediately upon application if they qualify for assistance.Īpplication Process: CPR offers four (4) points of entry into the program accepting applications daily. All funds have income guidelines of either 300% or 400% or less of the Federal Poverty Guideline (FPG) with consideration for the Cost of Living Index (COLI) and the number in the household. Patient's income must fall below the income guidelines of the fund under which they are requesting financial assistance. Patient must reside and receive treatment in the United States. Patient must have a physician confirmed diagnosis of the disease under which they are requesting financial assistance. Contact your State Medical Assistance (Medicaid) office to get details about these cost-saving programs. territories also have programs that help people with limited income and resources pay their Medicare costs. * Operating as an independent division within PAF, this program provides direct financial assistance with co-payments, co-insurance and deductibles required by your insurer for pharmaceutical treatments and/or prescription medications relative to your diagnosis.Įligibility: Patient must be currently insured and have coverage for the medication(s) for which they seek financial assistance. Medicaid a joint federal and state program that helps cover medical costs for some people with limited income and resources.
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