Pfizer RxPathways Updates

The 2025 benefit changes outlined in the Inflation Reduction Act will help many Medicare Part D/Medicare Advantage patients, including (1) the reduction of out-of-pocket prescription costs for covered medicines to $2,000 annually and (2) a voluntary option for enrollment in the Medicare Prescription Payment Plan.

All Medicare Part D/Medicare Advantage enrollees seeking access to the Pfizer Patient Assistance Program for the 2025 enrollment year, must attest to and provide evidence of their enrollment in the Medicare Prescription Payment Plan. In addition, patients must apply to all applicable ICPAPs and continue to provide proof of ICPAP denial, from each before being considered for PAP. These requirements will immediately be applied to all 2025 enrollment form submissions.

To demonstrate proof of MPPP enrollment, patients can provide a paper letter or email confirmation, or screen shot of enrollment. Missing proof of enrollment in MPPP will prevent the enrollment form from being processed for patients with an annual pre-tax household income above 138% of the FPL.

To demonstrate proof of denial from all ICPAPs to which a patient was referred, patients should include a paper or email notification, or screen shot of the denial from the ICPAP(s) indicating their denial for support. In certain circumstances, if the ICPAP does not provide written documentation, we will accept a patient’s verbal confirmation that they were denied along with the reason for denial. Applications will not be processed until/unless the documentation is received.

Pfizer’s PAP is a last resort, safety net program, for patients with the most financial need. As such, we encourage patients to explore all of their options, and if the patient’s prescription costs remain unaffordable after this, only then should patients consider applying for the PAP.

Medicare beneficiaries have the option to enroll in the Medicare Prescription Payment Plan during the Medicare Part D/Medicare Advantage Open Enrollment Period (which began on October 15th, 2024), as well as at any time during the plan year. For more information on the Medicare Prescription Payment Plan and how to enroll, patients can call their health plan, visit their plan’s website, and/or visit: https://www.medicare.gov/prescription-payment-plan.

The decision to enroll in the Medicare Prescription Payment Plan is voluntary and completely up to the patient. If the patient chooses not to enroll in the Medicare Prescription Payment Plan, they will not be eligible for enrollment/re-enrollment in the Pfizer Patient Assistance Program. We encourage the patient to discuss this with their healthcare provider.

All changes are effective January 1, 2025. Patients who have already submitted their application in 2024 and are awaiting their PAP determination for 2025 will be informed if they need to take additional action such as providing proof/documentation of MPPP enrollment and/or ICPAP denials.

Periodically, Pfizer reviews the PAP to confirm it is supporting the evolving needs of patients in a rapidly changing healthcare environment. These changes are a response to the Inflation Reduction Act which caps Medicare Part D/Medicare Advantage patients’ annual out of pocket prescription drug costs for covered medicines at $2,000 and enables patients to have the option to enroll in the Medicare Prescription Payment Plan to spread out their monthly medicine costs.

Pfizer may adjust the PAP in coming years in accordance with changes in the healthcare landscape, including but not limited to, new policies and regulations that impact patients’ ability to afford their Pfizer medicine and vaccines.**

Instamos a los pacientes a consultar a su proveedor de atención médica y (o) a su aseguradora para explorar las opciones que mejor se adapten a sus necesidades médicas y económicas. También hay otros recursos que probablemente puedan ayudar a los pacientes afectados por estos cambios (dependiendo del medicamento o de la vacuna), como, por ejemplo, NeedyMeds, RxOutreach (entre otros); tarjetas comerciales para copago de medicamentos (sujetas a restricciones); y programas de descuentos en farmacias locales.

Pacientes y proveedores de atención médica: favor de llamar al 1-844-989-PATH (7284). 

The income eligibility criteria for all patients applying to the PAP for assistance with any product other than a vaccine remains at an annual pre-tax household income at or below 300% Federal Poverty Level (FPL) adjusted for household size. (Federal Poverty Level Guidelines available at https://aspe.hhs.gov/poverty-guidelines). Effective January 1, 2025, the FPL limit for all products, including vaccines will be 300% of the FPL. Though the FPL Guidelines are subject to change in January of each year, currently 300% of the FPL in the 48 contiguous states excluding Alaska and Hawaii is:

Yes. Patients without an insurance plan who meet the income eligibility criteria may be eligible for the PAP if all other PAP eligibility criteria are met.

Yes. Patients who have public insurance, meet the income eligibility criteria, and have a valid, on- label prescription from their healthcare provider may be eligible for the PAP, assuming all criteria have been met for the program. Public Insurance includes, but is not limited to Medicare Part D/Medicare Advantage, Medicaid, Champus/TRICARE & VA.

No, commercially- insured patients are not eligible for the Pfizer PAP.

Yes, patients currently enrolled in the PAP may be eligible for re-enrollment in the PAP program in 2025 if their annual pre-tax household income is at or below 300% of the Federal Poverty Level (FPL) and they meet all other 2025 eligibility requirements.

NOTE: This list of products is subject to change