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Xelsource Answers and Support for Xeljanz

This program provides brand name medications at no or low cost

Provided by: Pfizer, Inc.

2730 S. Edmonds Lane,
Suite 300,
Lewisville, TX 75067

TEL: 844-935-5269


FAX: 866-297-3471
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Xelsource Pfizer Patient Assistance Application for Xeljanz

Xelsource Prescription Information & Enrollment Form (RA, PsA)

Xelsource Prescription Information & Enrollment Form (UC)

 

Medications

  • Xeljanz XR tablet; extended release (tofacitinib)
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must reside in the US
   

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 notified in writing
Decision Timeframe Varies
   

Medication

Amount/Supply Varies
Sent To Patient's home
Delivery Time Once approved; within 2 business days
Refill Process Patient or Doctor must contact company
Limit None
Re-application New application, new documentation yearly
   

Additional Information

Pfizer also has programs that provide eligible patients with insurance, support assistance, and medicines at a savings.

This program also provides copay assistance.

Updated October 18, 2021


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • Xeljanz XR tablet; extended release (tofacitinib)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

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.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.

Updated September 27, 2021