Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 4.
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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


FAX: 866-470-1748
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Pfizer Group A Application for Primary Care Medicines

Pfizer Group A Application for Primary Care Medicines (Spanish)

Pfizer Group B Application for Oncology and Specialty medicines

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

Pfizer Group C Application for Vaccines

Pfizer Group C Application for Vaccines (Spanish)

 

Medications

  • sildenafil tablet (Revatio) Tablet
 

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 Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply Varies
Sent To Varies
Delivery Time Varies
Refill Process Varies per medication
Limit None
Re-application New application, new documentation yearly
   

Additional Information

*Trumenba: Eligibility determined on a case-by-case basis.

This program also offers a savings program, insurance counseling, and other support services. Contact Program for details.


Updated August 23, 2016


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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Good Days Program

This is a copay assistance program.

Provided by: Good Days from CDF

6900 Dallas Parkway
Ste. 200
Plano, TX 75024

TEL: 877-968-7233


FAX: 214-570-3621
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Good Days Program Patient Enrollment Application 2016 (pages: 3-5)

Good Days Program Enrollment Information Pages for 2016 (pages: 1, 2 & 6)

 

Medications

  • sildenafil (Revatio) 
 

Eligibility Requirements   

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax, mail or submit online
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Must re-enroll at end of calendar year
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Updated June 01, 2016


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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HealthWell Foundation Copay Program

This is a copay assistance program.

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

 HealthWell Foundation Copay Program: Contact program

 

Medications

  • sildenafil (Revatio) 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated August 04, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 4.
 

Rx Outreach Medications

This program provides medication at low cost. (Most brand names are provided for reference purposes only.)

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Rx Outreach Application

Rx Outreach Diabetic Supplies Order Form (Prodigy)

Rx Outreach Refills and New Prescription Form

Rx Outreach Medication List

Rx Outreach Medication List (Spanish)

 

Medications

  • sildenafil (Revatio) 
 

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, mailed or downloaded from website
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and 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 Rx Outreach website for the exact price and most current medication list.

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


Updated July 28, 2016