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Enroll in the Co-Pay
Savings Program

The program can help people save on their PAXLOVID prescription.
See if you qualify below.

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Complete the enrollment form below to see if you are eligible for the Co-Pay Savings Program and to download a co-pay card.

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Enter your personal information and be sure that it is accurate.
If you are eligible, download your co‑pay card.
That’s it! Simply present your co-pay card to the pharmacist when you pick up your PAXLOVID prescription.
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Did you receive a physical co-pay card from your healthcare provider? Activate it here or over the phone by calling 1‑877‑219‑7225.

Activate Co-Pay Card

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Please confirm if any of the following statements are true for the person enrolling:

  • I have insurance from any federal healthcare program (including Medicare, Medicaid, TRICARE, or any other state or federal medical pharmaceutical benefit program or pharmaceutical assistance program)
  • My partner and I are both over 65 years of age and retired
  • I receive Social Security Disability Insurance (SSDI) or any other Social Security Administration (SSA) benefit
  • I receive insurance from the military

We’re sorry, you are not eligible for the Co-Pay Savings Program.

You may still qualify for PAXLOVID at no charge,* or you may qualify for other programs.† Please visit PAXCESSpatientportal.com for more information or reach out to 1-877-C19-PACK (1-877-219-7225) to see what options may be available for you.

*Other administrative fees may apply.

†With a focus on ensuring access for patients, the U.S. Government Patient Assistance Program (USG PAP) operated by Pfizer will continue to provide eligible patients on Medicare, Medicaid, TRICARE, VA Community Care Network, and those who are uninsured access to PAXLOVID for free through December 31, 2025. PAXLOVID through USG PAP is not available to patients who have commercial prescription drug health insurance. The USG PAP operated by Pfizer is an independent program with separate eligibility requirements offered by the United States Department of Health and Human Services and is not owned by Pfizer. Terms and conditions apply. Full terms and conditions for the USG PAP may be found here.

All fields are required unless otherwise noted.
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CONSENT TO COLLECT AND USE PERSONAL HEALTH INFORMATION

Pfizer Inc. (“Pfizer”) collects certain personal health information (described below) about individuals so that it may operate a co-pay program (the “Program”). Pfizer is seeking this consent because it needs to collect, use and disclose such information, which is considered sensitive information in some states, in connection with operation of the Program.

Health Information Collected and Used. The personal health information Pfizer and its service providers collect includes name, patient identifier, test results, medical records, healthcare provider information, other data that identifies that you are seeking health care services, and data otherwise related to your health condition, diagnosis, and/or treatment (collectively “Health Information”).

Purposes of Collection and Use. Your Health Information will be used for the following purposes:

· Working with enrollee’s applicable health insurance plan to understand or verify coverage for the Program
· Applying to the Program
· Determining enrollee’s eligibility for and facilitating enrollment into financial assistance services if eligible, including co-pay assistance
· Ensuring quality and safety and improving Pfizer’s products and services
· Contacting me by various media channels with marketing related content about Pfizer’s products and services

Duration. I permit such use of my Health Information for one year after the date I sign this consent, unless and until I revoke (i.e., take back) it in writing prior to that time.

Revocation. I may revoke this consent at any time, except to the extent that Pfizer has taken any action in reliance on my consent. I understand that if I revoke this consent, it will not have any effect on any use of my Health Information that occurred prior to receiving my revocation. If I would like to revoke my approval, I may contact my physician or I may contact PAXCESS, PO Box 592188, Orlando FL 32825, M–F 9 AM–9 PM, Sat–Sun 9 AM–5 PM, and 1-877-219-7225.

I understand that this consent to collect, use and disclose my Health Information is voluntary and may be revoked in writing at any time. I further understand that not permitting the processing of my Health Information may result in my health plan or insurer not being able to participate in the Program.

I have read this consent and/or had its contents read to me. I fully understand the terms and conditions described above.

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