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Finding forms for patient access. Together.

Find forms to help patients access their prescribed Pfizer Oncology medications, as well as resources for processing claims and submitting prior authorizations and appeals.

Program Enrollment

Pfizer Oncology Together Enrollment Form


Spanish Pfizer Oncology Together Enrollment Form

Additional Resources

ENROLLMENT FORM COMPLETION GUIDE


ACCESS GUIDE FOR PFIZER ONCOLOGY MEDICATIONS (FOR HEALTHCARE PROFESSIONALS)


PFIZER ONCOLOGY PATIENT ACCESS GUIDE (FOR PATIENTS)


SPANISH ACCESS GUIDE FOR PFIZER ONCOLOGY MEDICATIONS (FOR PATIENTS)

Product Access

Specialty Pharmacies


BESPONSA® (inotuzumab ozogamicin) & MYLOTARG™ (gemtuzumab ozogamicin) Specialty Distributors


Injectable biosimilars are available through most major wholesalers.

Please see full Prescribing Information for BESPONSA, including BOXED WARNING, or visit BESPONSAhcp.com.

Please see full Prescribing Information for MYLOTARG, including BOXED WARNING, or visit MYLOTARGhcp.com.

Sample Letters & Checklists*

Letter Of Medical Necessity Checklist


Sample Letter Of Medical Necessity


Prior Authorization Checklist


Appeals Checklist


Sample Letter Of Appeals


Sample Letter For Requesting FORMULARY Exception


*The information contained in these template letters is provided by Pfizer for informational purposes for patients prescribed a Pfizer medicine. These templates are not intended to substitute for a prescriber’s independent medical decision-making.

Billing & Coding Information

BIOSIMILARS:

NIVESTYM® (filgrastim-aafi) BILLING & CODING GUIDE


NYVEPRIA™ (pegfilgrastim-apgf) Billing & Coding Guide


RETACRIT® (epoetin alfa-epbx) Billing & Coding Guide


RUXIENCE® (rituximab-pvvr) Billing & Coding Guide


TRAZIMERA® (trastuzumab-qyyp) Billing & Coding Guide


ZIRABEV® (bevacizumab-bvzr) Billing & Coding Guide


View Q codes for BIOSIMILAR medications

BESPONSA® (inotuzumab ozogamicin) & MYLOTARG™ (gemtuzumab ozogamicin)

BESPONSA Sample UB-04/CMS-1450 Form For Hospital Outpatient Use


BESPONSA Sample CMS-1500 Form For Physician Office Use


MYLOTARG Sample UB-04/CMS-1450 FORM FOR HOSPITAL OUTPATIENT USE


MYLOTARG Sample CMS-1500 Form For Physician Office Use


Please see full Prescribing Information for BESPONSA, including BOXED WARNING, or visit BESPONSAhcp.com.

Please see full Prescribing Information for MYLOTARG, including BOXED WARNING, or visit MYLOTARGhcp.com.

Please see full Prescribing Information for RETACRIT, including BOXED WARNING and Medication Guide, or visit RETACRIThcp.com.

Please see full Prescribing Information for RUXIENCE, including BOXED WARNING and Medication Guide, or visit RUXIENCEhcp.com.

Please see full Prescribing Information for TRAZIMERA, including BOXED WARNING, or visit TRAZIMERAhcp.com.

The information provided here is intended for informational purposes only and is not a comprehensive description of potential coding requirements for BESPONSA, MYLOTARG, ZIRABEV, RUXIENCE, TRAZIMERA, RETACRIT, and NIVESTYM. Coding and coverage policies change periodically and often without warning. The healthcare provider is solely responsible for determining coverage and reimbursement parameters and accurate and appropriate coding for treatment of his/her own patients. The information provided in this section should not be considered a guarantee of coverage or reimbursement for BESPONSA, MYLOTARG, ZIRABEV, RUXIENCE, TRAZIMERA, RETACRIT, and NIVESTYM.

The sample forms are intended as a reference for billing and coding of BESPONSA, MYLOTARG, ZIRABEV, RUXIENCE, TRAZIMERA, RETACRIT, and NIVESTYM. These forms are not intended to be directive or to replace clinical decision-making, and the use of the recommended codes does not guarantee reimbursement. Healthcare providers may deem other codes or policies more appropriate and should select the coding options that most accurately reflect their internal guidelines, payer requirements, practice patients, and the services rendered.

Co-pay Assistance

Co-Pay Savings Program Claim Form (Injectables)


Overview for Enrollment and Claim Submission (INJECTABLES)


CO-PAY SAVINGS Program for Oral Products Brochure (For Patients)


CO-PAY SAVINGS PROGRAM FOR Injectable PRODUCTS BROCHURE (FOR PATIENTS)


AROMASIN® (exemestane) SAVINGS CARD TIP SHEET


BIOSIMILAR RESOURCES

NIVESTYM Co-Pay Savings Program Brochure


NYVEPRIA Co-Pay Savings Program Brochure


RUXIENCE CO-PAY SAVINGS PROGRAM BROCHURE


TRAZIMERA CO-PAY SAVINGS PROGRAM BROCHURE


ZIRABEV CO-PAY SAVINGS PROGRAM BROCHURE


Please see full Prescribing Information for RUXIENCE, including BOXED WARNING and Medication Guide, or visit RUXIENCEhcp.com.

Please see full Prescribing Information for TRAZIMERA, including BOXED WARNING, or visit TRAZIMERAhcp.com.

HELPFUL PATIENT RESOURCES

Download sample resources from the Care Champion Program for your practice.