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Program 1 of 4.
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Updated April 14, 2014

Pfizer RxPathways Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Pfizer, Inc.

PO Box 66585
St. Louis, MO 63166-6585

TEL: 866-706-2400


ALT PHONE:
FAX: 866-470-1748
Languages Spoken:

English, Spanish

Program Website
 

Patient Assistance Applications

Pfizer Group A Application for Primary Care medicines

Pfizer Group B Application for Oncology and Specialty medicines

Pfizer Group C Application for Vaccines

Pfizer Group A Application for Primary Care medicines (Spanish)

Pfizer Group B Application for Oncology and Specialty medicines (Spanish)

Pfizer Group C Application for Vaccines (Spanish)

 

Medications

  • hydroxyzine Capsule dosage varies (Vistaril)
 

Eligibility Requirements

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Not specified
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining Call or download
Receiving Mailed or downloaded from website
Returning Mail or fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 4 weeks
   

Medication

Amount/Supply Varies
Sent To Address of shipment varies by medication *See Additional Information section below
Delivery Time Within 2-4 weeks
Refill Process Patient or Doctor must contact company
Limit None
Re-application New application, new documentation yearly
   

Additional Information

*Lyrica, oral oncology, and specialty products are shipped to the patient's home, other medications to Doctor's office

For help with Prevnar 13, please contact customer service and talk to your health care provider. This program was formerly known as Pfizer Helpful Answers



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 2 of 4.
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Updated March 04, 2014

Rx Outreach Medications

This program provides both brand name and generic medications at no or low cost.

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


ALT PHONE: 888-RXO-1234
FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website
 

Patient Assistance Applications

Rx Outreach Application

Rx Outreach Diabetic Supplies

Rx Outreach Medication List

Rx Outreach Refills and New Prescriptions Order Form

 

Medications

  • hydroxyzine Capsule 25mg, 50mg (Vistaril)
 

Eligibility Requirements

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed or mailed
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign
Decision Communicated Medications sent if accepted. If denied patient and Doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the website for the exact price.

Contact Program for Spanish Application(s)/Form(s)



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 3 of 4.
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Updated April 14, 2014

Xubex Patient Assistance Program

This program provides generic medications at a discount.

Provided by: Xubex

PO Box 1244
Winter Park, Fl 32790-1244

TEL: 866-699-8239


ALT PHONE: 407-478-2663
FAX: 407-671-7960
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Xubex Patient Assistance Program Registration Form

Xubex Patient Assistance Program Physician Order Sheet

 

 

Medications

  • hydroxyzine Capsule 25mg, 50mg (Hydroxyzine Pamoate)
 

Eligibility Requirements

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Varies per medication
Re-application New application, new documentation yearly
   

Additional Information

No proof of income is required. Check the website for the exact price.



Don't qualify for this program?
Visit the DBAs to look for financial assistance based on your diagnosis.

Program 4 of 4. Updated April 14, 2014

Pfizer RxPathways Savings Card

This is a discount card program.

Provided by: Pfizer, Inc.


TEL: 866-706-2400


ALT PHONE:
FAX:
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

 Pfizer RxPathways Savings Card: Contact program

 

Medications

  • hydroxyzine Capsule dosage varies (Vistaril)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage
Those with Part D Eligible? No
Income Not Required
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining No application
Receiving Not applicable
Returning Not applicable
Doctor's Action Give prescription to patient
Applicant's Action Call to enroll
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not applicable
Sent To Card sent to doctor's office or to patient's home
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information