Packaging - 2 X 10 Tablets in 1 Pack. Revised 3/1/2011 BRISTOL-MYERS SQUIBB PATIENT ASSISTANCE FOUNDATION, INC. P.O. Help you find out if ELIQUIS is covered by your insurance plan, Determine if you are eligible for assistance paying for ELIQUIS, Check if you qualify for the ELIQUIS Co-pay Card. Enter your ZIP Code to locate participating clinics, health centers, and hospitals near you. To qualify for free medicine through the Pfizer Patient Assistance Program, patients must*: *In addition to those noted here, other requirements may apply. If you are a Patient already enrolled in Pfizer's Patient Assistance Program, you can register by providing your email, name and Patient ID (used to validate your account). Then, click below to activate it. Spinal or epidural blood clots (hematoma). If you get this reaction, it will usually happen soon after you take a dose of ELIQUIS. All other trademarks are property of their respective companies. See if youre covered by tapping to call 1-855-ELIQUIS (354-7847). Choose the fillable fields and include the necessary information. All decisions regarding patient care must be made with a healthcare provider, considering the unique characteristics of the patient. 2022 Bristol-Myers Squibb Company. Additional products may be made available in the future. You are about to leave the Bristol Myers Squibb and Pfizer hcp.eliquis.com site. Elise isn't available for Internet Explorer. Also, medicines that are typically only administered to hospital inpatients are not available through the program. Bristol Myers Squibb and Pfizer are not responsible for the content of such other sites and shall not be liable for any damages or injury arising from users access to such sites. All forms are printable and downloadable. Stopping ELIQUIS increases your risk of having a stroke. When at the pharmacy, give the card to your pharmacist and they will enter it into their system. TEL: 800-736-0003 FAX: 800-736-1611: Languages Spoken: English, Spanish, Others By Translation Service If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. For People at Risk of Stroke due to AFib Not Caused by a Heart Valve Problem. You are about to leave the Bristol Myers Squibb and Pfizer ELIQUIS.com site. NVAF Hospital Discharge Kit & Discharge Planning Checklist, VTE Hospital Discharge Kit & Discharge Planning Checklist, This site is intended for U.S.HealthcareProfessionals. Meet the executive leadership team, our senior-most leadership and decision-making management body who focus on major financial, strategic, and operational decisions for the entire company. PDF New Patient Application - Patient Assistance For more information, please visitwww.Pfizer.com/responsibility. Pfizer regularly updates the list of covered products. Important: Please note that a unique email address is required for each HCP, officer registration delegate and access coordinator while creating an account. Through Pfizer RxPathways, Pfizer can also help connect patients to other assistance services the company offers if they are not eligible to receive their medicines for free. If you have to stop taking ELIQUIS, your doctor may prescribe another medicine to help prevent a blood clot from forming. Links to select publications for ELIQUIS phase III clinical trials are provided below. To the pharmacist: For processing assistance, please call McKesson Pharmacy Support at 866-279-4730. To learn more, please visit us atwww.pfizer.com. Prior authorization: If your insurance plan needs prior authorization before approving coverage ofELIQUIS, live specialists can help coordinate the process among your doctors, insurer, and pharmacist, and get the paperwork submitted. Click below to reactivate a Co-pay Card youve already activated in the past. Please contact Pfizer Canada Medical Informationat 1 800 463-6001 with any comments or inquiries. Get medical help right away if you have sudden chest pain or chest tightness, have sudden swelling of your face or tongue, have trouble breathing, wheezing, or feeling dizzy or faint. ELIQUIS and the ELIQUIS logo are trademarks of Bristol-Myers Squibb Company. For those customers using mail-order or any non-participating retail pharmacy, please call tap to call 866-279-4730 torequest a patient rebate form, or go to www.patientrebateonline.com to download aform, By using this card, you and your pharmacist understand and agree to comply with the eligibility requirements and terms of use, Present your activated Free Trial Offer Card to your pharmacist along with your ELIQUIS prescription, Eligible patients who present a Free 30-Day Trial card together with a valid 30-day prescription for ELIQUIS at participating pharmacies can receive a free 30-day supply (up to 74 tablets) of ELIQUIS. You should not do both. If you are a new Patient, you can create a new account and being your enrollment process. For a complete list of available medicines, please visit www.PfizerRxPathways.com. Patients, pharmacists, and prescribers cannot seek reimbursement, from health insurance or any third party, for any part of the benefit received by the patient through this offer. Participants could possibly be featured in videos as well as a wide range of promotional materials if selected. unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier than normal, bleeding that is severe or you cannot control, red, pink, or brown urine; red or black stools (looks like tar), coughing up or vomiting blood or vomit that looks like coffee grounds. Program Offers Assistance to Insured and Uninsured Patients. You are about to leave the Bristol Myers Squibb and Pfizer hcp.eliquis.com site. Refill your prescription before you run out. To use Elise, please try going to this website on a phone, tablet, or another internet browser, such as Chrome, Firefox, or Safari. Pfizer CentreOne; Submit Your Opportunities; Investors Careers Media . Your doctor will tell you when you should stop taking ELIQUIS and when you may start taking it again. (as of July 6, 2022). They are, however, still being made available to uninsured patients through the Pfizer Savings Program. Females who are able to become pregnant: talk with your healthcare provider about pregnancy planning, and your risk of severe uterine bleeding if you are treated with blood thinner medicines, including ELIQUIS. Currently Pfizer PAP Connect is available for the most commonly requested primary care medications9 offered by Pfizers Patient Assistance Program. A reaction to ELIQUIS can cause hives, rash, itching, and possibly trouble breathing. The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation. What should I discuss with my healthcare team before starting ELIQUIS? You may have a higher risk of bleeding if you take ELIQUIS with other medicines that increase your risk of bleeding, such as: Tell your doctor if you take any of these medicines. Estimated savings range from 36 to 75 percent and depend on factors such as the particular drug purchased, amount purchased, and the pharmacy where purchased. For more information about Pfizer RxPathways, please visit www.PfizerRxPathways.com. You can also sign up to receive helpful information about your condition and taking ELIQUIS. Learn about SARS-CoV-2, the coronavirus that causes COVID-19, what you can do to stay safe and prevent the spread, and our scientific efforts to help bring an end to the current global health crisis. Talk to your healthcare team about the following: Tell your doctor if you are pregnant or breastfeeding, or planning to become pregnant or breastfeed. 1-800-721-5072 (toll free U.S. only) As of 2019, Bristol Myers Squibb and Celgene have merged. With NiceRx you'll always pay a flat monthly fee of $49. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. Applies to: Eliquis Number of uses: Contact the program Form more information phone: 855-354-7847 or Visit website Patient Assistance & Copay Programs for Eliquis In response to the ongoing challenges patients face in paying their out-of-pocket costs for their prescription medicines, Pfizer announced today that it will immediately double the allowable income level for its patient assistance program, so that even more patients in need could be eligible to receive their Pfizer medicines for free. For more information, please call the toll-free number 1-866-706-2400. The Pfizer Patient Assistance Program provides certain medicines for free to eligible financially needy insured and uninsured patients. Pfizer PAP Connect | Pfizer RxPathways This site is intended for U.S. residents 18 years of age or older. Live in the United States, Puerto Rico, or US Virgin Islands. Please see Full Prescribing Information, including Boxed WARNINGS and Medication Guide. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. You are being redirected to a Pfizer corporate site. Contact us at 1-866-706-2400for Enrolled PAP Patients. Call Tap to call 1-855-ELIQUIS (354-7847) from Monday Friday, 8 AM 8 PM (ET). There are no membership fees to participate in this program. to know about ELIQUIS. Contact us at 1-866-706-2400for Enrolled PAP Patients. Please note office staff can use the system after the healthcare provider creates an account and invites the staff member to register and access that account. Our logo is shorthand for everything Pfizer represents: an image that is instantly identifiable to our colleagues, patients, the external scientific community, and the public. Spinal or epidural blood clots (hematoma). You can also ask Elise, our virtual assistant, for help or you can tap to call 1-855-ELIQUIS (354-7847). You are about to leave the Bristol Myers Squibb and Pfizer hcp.eliquis.com site. Who can get help through the Pfizer Patient Assistance Program? You can also ask Elise, our virtual assistant, for help or you can call 1-855-ELIQUIS (354-7847). Please call1-844-989-PATH (7284), PAP Connect enables US patients and their healthcare providers to apply and manage their enrollment for select primary care medicines in the Pfizer Patient Assistance Program completely online through their mobile device or computer*. Your doctor or healthcare provider will determine what dose is right for you. Enter the name of your prescribed medicines and follow the onscreen instructions. Is Eliquis made by Pfizer? Increased Risk of Thrombotic Events after Premature Discontinuation: Concomitant use of drugs affecting hemostasis increases the risk of bleeding, including aspirin and other antiplatelet agents, other anticoagulants, heparin, thrombolytic agents, SSRIs, SNRIs, andNSAIDs. The Pfizer Patient Assistance Foundation is a separate legal entity from Pfizer Inc., with distinct legal restrictions. determine my eligibility for the ELIQUIS co-pay assistance program, refer me to . To the pharmacist: For processing assistance, please call McKesson Pharmacy Support at 1-866-279-4730. Card must be activated before use. How does a patient or healthcare provider sign up for Pfizer PAP Connect? For certain Pfizer medicines, patients and healthcare providers can complete the application process online through Pfizer PAP Connect. Pfizer Patient Assistance Program Number The health information contained herein is provided for educational purposes only and is not intended to replace discussions with a healthcare provider. With this change, more than 40 medicines offered for free through the program will now be available to eligible patients earning up to 4 times the Federal Poverty Level (FPL) adjusted for family size ($47,080 for a single person; $97,000 for a family of four). Patients who participate in any federal or state healthcare programs, such as Medicaid or Medicare, are not eligible for co-pay assistance. BristolMyers Squibb and Pfizer reserve the right to rescind, revoke, or amend this offer at any time without notice. This website is best viewed using the horizontal display on your tablet device. You may have a higher risk of bleeding if you take ELIQUIS and take other medicines that increase your risk of bleeding, such as aspirin, nonsteroidal anti-inflammatory drugs (called NSAIDs), warfarin (COUMADIN), heparin, selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs), and other medicines to help prevent or treat blood clots. Eliquis Patient Assistance Form - Printable Blank PDF Online ELIQUIS is covered for over 90% of patients Estimated savings range from 36 to 75 percent and depend on factors such as the particular drug purchased, amount purchased, and the pharmacy where purchased. To qualify for free medicine through the Pfizer Patient Assistance Program, patients must*: The difference in the program for uninsured patients vs. underinsured patients is that uninsured patients are enrolled for 12 months but patients with insurance are enrolled through the end of a calendar year, since many people switch plans at the end of the calendar year. You are encouraged to report negative side effects of prescription drugs to the FDA. These are not all of the possible side effects of ELIQUIS. Do you require proof of US citizenship as part of the application process? Be treated by a healthcare provider licensed in an outpatient setting in the United States, Puerto Rico, or US Virgin Islands. Payment assistance will vary based on your insurance plan coverage of the original brand medication. Consider these risks when scheduling patients for spinal procedures. 1-800-FDA-1088. Get medical help right away if you have any of the following symptoms: Sudden chest pain or chest tightness Sudden swelling of your face or tongue Trouble breathing Wheezing Currently Pfizer PAP Connect is available for the most commonly requested primary care medications, or to begin the application process, visit Pfizer PAP Connect at, Have a valid prescription for the Pfizer medicine for which they are seeking assistance, Have no prescription coverage, or not enough coverage, to pay for their Pfizer medicine, Meet income guidelines, which vary by medicine, but start at 400% of the Federal Poverty Level, adjusted for family size, Be treated by a healthcare provider licensed in the U.S. or a U.S. territory, Be at or below 400% of the Federal Poverty Level, adjusted for family size, Reside in the U.S. (migrant and homeless patients are presumed eligible). You may have a higher risk of bleeding if you take ELIQUIS and take other medicines that increase your risk of bleeding, such as aspirin, nonsteroidal anti-inflammatory drugs (called NSAIDs), warfarin, heparin, selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs), and other medicines to help prevent or treat blood clots. Upon expiration, eligible patients may re-enroll in the Co-pay Card Program. Card expires 24 months from activation. You will need be connected to the internet to access Pfizer PAP Connect. For patients who are unable to participate online, maintain a fully manual process. Combined P-gp and Strong CYP3A4 Inducers: The limited available data on ELIQUIS use in pregnant women are insufficient to inform drug-associated risks of major birth defects, miscarriage, or adverse developmental outcomes. You can provide your e-signature by visiting www.ELIQUIS.com/sign. If your prescriber is unable to get ELIQUIS approved, and if you are eligible, we will refer you to other co-pay assistance programs or the patient assistance program. ELIQUIS (apixaban) is a prescription medicine used to reduce the risk, ELIQUIS (apixaban) is a prescription medicine used to treat blood clots, This is a summary of important safety information that you need, Do not stop taking ELIQUIS without talking to the doctor who prescribed it to you. ELIQUIS may need to be stopped prior to surgery or a medical or dental procedure. 4Terms and conditions apply. 1 The Pfizer Patient Assistance Program is a joint program of Pfizer Inc. and the Pfizer Patient Assistance Foundation. Patients can also call the toll-free phone number 1-844-989-PATH (7284) to consult with a Pfizer Medicine Access Counselor. If you work with multiple providers, each provider has to register first and then invite you using the Invite Staff button. Sorry, you need to enable JavaScript to visit this website. You may qualify for the Pfizer Savings Program. Unleashing the next wave of scientific innovations, Research and Business Development Partnerships, Savings ranging from 35% to 50% off the retail price on Pfizer medicines for uninsured patients regardless of income, Medicine access counseling to help patients get connected to the appropriate Pfizer assistance program, Insurance counseling for select Pfizer medicines to help patients understand the coverage offered through their insurance plans, Co-pay cards for those with private/commercial insurance and information on alternate sources of help, like independent co-pay foundations, Referrals to other industry resources that may help if it is discovered a patient is not taking a Pfizer medicine. Fax the signed copy to 1-855-674-8134. . For a complete list of participating pharmacies, please visit www.pfizerrxpathways.com or call the toll-free number 1-866-989-PATH (7284). ELIQUIS 360 Support is here to help you understand your prescription coverage and help thosewith an ELIQUIS prescription learn about ways to save on out-of-pocket costs. Please call1-844-989-PATH (7284). We strive to set the standard for quality, safety and value in the discovery, development and manufacture of health care products. Look out for the following icons as you read: Do not stop taking ELIQUIS without talking to the doctor who prescribed it to you Patient is responsible for applicable taxes, if any. You will immediately be covered for most, if not all . Im an uninsured patient and I dont meet the requirements for the Pfizer Patient Assistance Program. Combined P-gp and Strong CYP3A4 Inhibitors: Although clarithromycin is a combined P-gp and strong CYP3A4 inhibitor, pharmacokinetic data suggest that no dose adjustment is necessary with concomitant administration withELIQUIS. Reduce the risk of forming a blood clot in the legs (DVT) and lungs (PE) of people who have just had hip or knee replacementsurgery. Strength in Sharing was established to give selected ELIQUIS patients an opportunity to share experiences and insights that may be helpful to other patients. 2 Product availability varies by institution and eligibility. Terms and conditions apply. Who is at risk for AFib not caused by a heart valve problem? Estimated savings range from 36% to 75% and depend on such factors as the particular drug purchased, amount purchased, and the pharmacy where purchased. PP-UNP-USA-0905. The risk may also be increased by traumatic or repeated epidural or spinal puncture. For your convenience, you can access ELIQUIS 360 Support in 3 ways: Explore the topics on this page to request and/or activate a Co-pay Card, activate a Free Trial Offer, and sign up for helpful info and support, Talk to a live specialist by calling tapping to call 1-855-ELIQUIS (354-7847), Monday Friday, 8 AM 8 PM (ET) or Saturday Sunday, 9 AM 6 PM (ET). AFib Not Caused by a Heart Valve Problem. For questions, please call 1-877-744-5675, Monday-Friday, 8 am-8 pm ET. You are insured by commercial insurance and your prescription insurance coverage does not cover the full cost of your prescription, that is,you have a, You do not have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), or Department of Defense (DOD). After activation, you can opt-out at any time by texting STOP to 69108. Patients can go to the Pfizer RxPathways website or call a toll-free number to speak with a trained Medicine Access Counselor who will direct patients to Pfizer programs or other independent 3rd party resources. There are no membership fees to participate in this program. Monitor patients frequently and if neurological compromise is noted, urgent diagnosis and treatment is necessary. For more specific information on the application process, please visit www.PfizerRxPathways.com or call the toll-free phone number 1-844-989-PATH (7284) to consult with a Pfizer Medicine Access Counselor. Fill - Free fillable PFIZER PATIENT ASSISTANCE PROGRAM PDF form Call 1-877-744-5675 (Monday-Friday 8 AM -8 PM ET) for live support. with commercial & Medicare Part D plans Pfizer Inc, New York, NY. Patient is responsible for applicable taxes, if any. How does Pfizer RxPathways help patients? However, these patients may be eligible to receive their medicine for free through the Pfizer Patient Assistance Program. 1-800-FDA-1088. The Bristol-Myers Squibb-Pfizer Alliance will present 15 Eliquis (apixaban) posters at the ESC Congress 2018 held in Munich, Germany, August 25-29, 2018. By redeeming this offer, you certify that you have not previously filled a prescription for ELIQUIS. People who take ELIQUIS, and have medicine injected into their spinal and epidural area, or have a spinal puncture have a risk of forming a blood clot that can cause long-term or permanent loss of the ability to move (paralysis). Learn more about Prescription Coverage Assistance. Have no prescription coverage, or not enough coverage, to pay for their medicine. Your acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value received as may be required by your insurance provider. This offer may not be redeemed on prescriptions written for longer than 30 days. Tell your doctor about all of the medicines you take, including any over-the-counter medicines, vitamins, and herbal supplements. ELIQUIS is indicated for the treatment of DVT and PE, and to reduce the risk of recurrent DVT and PE following initialtherapy. Advise patients of signs and symptoms of blood loss and to report them immediately or go to an emergency room. ELIQUIS is indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE), in patients who have undergone hip or knee replacementsurgery. All Program payments are for the benefit of the patient only. To receive an ELIQUIS Free Trial Offer Card, pleaserequest one from your healthcare provider. Assistance Programs | Pfizer Canada Your doctor will tell you when you should stop taking ELIQUIS and when you may start taking it again. Payment assitance card form | Pfizer Originals PDF PFIZER Patient Assistance Program Form If you encounter technical difficulties in viewing our product information please contact Pfizer.ca Franais You are now leaving the Pfizer Canada website. Do not take ELIQUIS if you currently have certain types of abnormal bleeding or have had a serious allergic reaction to ELIQUIS. Present your activated Co-pay Card to your pharmacist, along with your ELIQUIS prescription, Eligible patients who present an activated Co-pay Card together with a valid prescription for ELIQUIS at participating pharmacies may pay as little as $10 per 30-day supply (up to 74 tablets for the first fill, and up to 60 tablets for all subsequent fills) for up to 24 months, subject to a maximum annual benefit of $6,400. LOVENOX is a registered trademark of Aventis Pharma S.A. Patients applying for free medicines may need to provide financial documentation with their application. You are about to leave the Bristol Myers Squibb and Pfizer ELIQUIS.com site. The risk of clinically significant uterine bleeding, potentially requiring gynecological surgical interventions, identified with oral anticoagulants including ELIQUIS should be assessed in these patients and those with abnormal uterine bleeding. PDF Patient Support Program Patient Assistance Enrollment Form No substitutions are permitted. For People at Risk of Stroke due to AFib Not Caused by a Heart Valve Problem. To learn more, go to, If patients are having trouble getting access to their Pfizer medication, they can visit www.PfizerRxPathways.com to use the Program Finder or call the toll-free phone number. Desktop, table, and mobile accessible with updates in real time, at any time. The Pfizer Savings Program1 helps patients without prescription coverage get savings on Pfizer medicines through participating pharmacies. Patients must also provide proof of income, such as a W2 form, a paycheck stub, or prior years tax return. Is Pfizer PAP Connect available on my mobile device? 1-855-ELIQUIS (354-7847). ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrialfibrillation (NVAF). Please verify that you are a U.S.HealthcareProfessional. Reduction in Risk of Recurrent DVT/PE Following Initial Therapy: concomitant use of other drugs that affect hemostasis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, otheranticoagulants, a history of traumatic or repeated epidural or spinalpunctures, a history of spinal deformity or spinalsurgery, optimal timing between the administration of ELIQUIS and neuraxial procedures isnotknown, Severe hypersensitivity reaction to ELIQUIS (e.g., anaphylacticreactions). Please note office staff can use the system after the healthcare provider creates an account and invites the staff member to register and access that account. Open the template in the online editing tool. A few clicks mean less paper and phone calls, and shipment tracking at your fingertips. If patients need help paying for medicines that are either not available through Pfizers assistance programs or not made by Pfizer, the following programs may be able to help. If you have questions along the way, our live specialists are available at 1-855-ELIQUIS (354-7847), Monday-Friday, 8 AM 8 PM ET. If you get this reaction, it will usually happen soon after you take a dose of ELIQUIS. Need to re-enroll to a program? Patients may not count the Free 30-Day Trial of ELIQUIS as an expense incurred for purposes of determining out-of-pocket costs for any plan, including true out-of-pocket costs, (TrOOP), for purposes of calculating the out-of-pocket threshold for Medicare Part D plans. See if youre covered by calling 1-855-ELIQUIS (354-7847). For all other Pfizer medicines, patients and healthcare providers should follow the existing application process outlined on the Pfizer RxPathways website. Free 30-Day Trial & $10 Co-Pay for Eligible Patients, Free 30-day trial offer for first-time patients andco-pay assistance for eligible patients prescribed ELIQUIS.*. Pfizer has been helping patients gain access to the Pfizer medicines they need for more than 25 years. Pfizer PAP Connect is available for the Pfizer Patient Assistance Program is a joint Program of Pfizer,! Invite Staff button that are typically only administered to Hospital inpatients are not eligible for Co-pay.! There are no membership fees to participate in any federal or state healthcare programs such. Rxpathways, please call 1-877-744-5675, Monday-Friday, 8 AM 8 PM ( ET ) and to reduce risk! Patient, you need to enable JavaScript to visit this website packaging - 2 X Tablets. To register first and then invite you using the invite Staff button outpatient setting in discovery! Provider sign up to receive helpful information about Pfizer RxPathways website and symptoms of blood loss and reduce. Is a separate legal entity from Pfizer Inc. and the ELIQUIS Co-pay Assistance provides... Them immediately or go to an emergency room these patients may be eligible to receive helpful information Pfizer. Selected ELIQUIS patients an opportunity to share experiences and insights that may be made available to uninsured patients Monday-Friday! From Pfizer Inc. and the Pfizer Patient Assistance Foundation ELIQUIS, your doctor will tell you when you start... The toll-free number 1-866-706-2400 I discuss with my healthcare team before starting ELIQUIS assistant, help... Number 1-866-706-2400 Patient, you certify that you have to stop taking ELIQUIS your! 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