Patient Assistance Program
Information for Health Care Professionals
For many years, Wyeth Pharmaceuticals has been committed to helping patients in need receive their medications. Through the Wyeth Patient Assistance Program, the Wyeth Pharmaceutical Assistance Foundation strives to ensure that eligible patients receive medications at no cost and in a timely manner. The following information answers common questions about our program and will assist with the application process.
To enroll a patient in the program, please complete the following steps:
- Obtain an application and privacy authorization form (see below).
- Complete the application in its entirety with the patient; please do not leave any section blank.
- Write a prescription for up to a 3-month supply and specify up to 3 refills, if appropriate. (Please note that Protonix® (pantoprazole sodium) is limited to a 60-day supply.)
- Obtain the patient's signature on the privacy authorization form allowing specified disclosure of health information to the Wyeth Pharmaceutical Assistance Foundation and retain in the patient's file.
- Mail the application form and prescription to the address indicated on the application.
The health care professional will determine whether the medication should be mailed to the patient's home or to the professional's office.
To receive general information, additional applications, and a list of products covered by the program via fax, call (800) 568-9938. If you would like to submit an inquiry to a Wyeth Pharmaceutical Assistance Foundation representative via the Web site, click here. To download an application, click here.
Qualification Guidelines
To receive medication through the Wyeth Pharmaceutical Assistance Foundation, patients must certify all of the following:
- They are unable to pay for their medication.
- They do not have government or private insurance to pay for the requested Wyeth medication or have depleted all other insurance coverage options such as Medicare, Medicaid, and other assistance from a government agency.
- They earn less than 200% of the current Department of Health and Human Services (HHS) Poverty Guidelines.
- They do not have other sufficient financial resources or assets to pay for the medication requested or that paying for the medication from their own resources or assets would cause severe hardship.
- They are residents of the United States or Puerto Rico.
Product Information
The following products are some of those covered by the Wyeth Pharmaceutical Assistance Foundation*:
- Effexor® (venlafaxine HCl) Tablets 25 mg, 37.5 mg, 50 mg, 75 mg, and 100 mg
- Effexor XR® (venlafaxine HCl) Extended-Release Capsules 37.5 mg, 75 mg, and 150 mg
- Phospholine Iodide® (echothiophate iodide for ophthalmic solution) 6.25 mg per 5 mL
- Premarin® (conjugated estrogens tablets, USP) 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, and 1.25 mg
- Premarin® (conjugated estrogens) Vaginal Cream 0.625 mg
- Premphase® (conjugated estrogens/medroxyprogesterone acetate tablets) 0.625 mg/5 mg
- Prempro® (conjugated estrogens/medroxyprogesterone acetate tablets) 0.3 mg/1.5 mg, 0.45 mg/1.5 mg,
0.625 mg/2.5 mg, and 0.625 mg/5 mg - Protonix® (pantoprazole sodium) Tablets 40 mg
- Trecator® (ethionamide tablets, USP) Tablets 250 mg
In addition, Wyeth has patient assistance programs for specific products. These programs may provide products or additional services. Refer to the information below for assistance:
- BeneFIX® Coagulation Factor IX (Recombinant) — The Hemophilia Reimbursement Hotline: (888) 999-2349
- Enbrel® (etanercept) — ENcourage Foundation®: (800) 393-4675
- Mylotarg® (gemtuzumab ozogamicin for Injection) — Wyeth Oncology Reimbursement Program:
(866) 993-8466 - Neumega® (oprelvekin) — Wyeth Oncology Reimbursement Program: (866) 993-8466
- Rapamune® (sirolimus) — RapAssist® Patient Assistance Program: (877) 472-7268
- ReFacto® Antihemophilic Factor (Recombinant) — Hemophilia Reimbursement Hotline: (888) 999-2349
- Torisel® (temsirolimus) injection — Torisel Reimbursement Hotline: (866) 993-8466
*This product list is subject to change at any time. For a complete list of products currently covered by the Wyeth Patient Assistance Program, call our toll-free number: (800) 568-9938.
The following medications are not covered by this program: over-the-counter products, diagnostics, controlled substances, oral contraceptives, and most injectables.
Frequently Asked Questions
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Will the Wyeth Patient Assistance Program provide help to Medicare beneficiaries?
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Like other pharmaceutical manufacturers’ patient assistance programs, the Wyeth program typically does not provide free medications to patients with prescription drug coverage, including Medicare Part D. Wyeth believes it is in the best health interests of people with Medicare to receive coverage through a Medicare drug plan or stay with their existing prescription insurance. But, on a case-by-case basis, the Wyeth Pharmaceutical Assistance Foundation will assist Medicare patients enrolled in Part D who otherwise meet the program’s income eligibility criteria and also demonstrate financial hardship—for example, by writing a letter or having their physician do so on their behalf. Individuals who are enrolled in Part D must also provide contact information for their Medicare drug plan so that Wyeth may communicate important information to their plan.
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How long does it take to receive medication?
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From receipt of a completed application, it takes approximately 7 to 10 days for medication to arrive at either the health care professional's office or the patient's home address.
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How can I obtain an application and authorization form for the program?
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Click on the following link to download a PDF of the application form. To have an application faxed to the health care professional or patient advocate, or mailed directly to the patient, call our toll-free number: (800) 568-9938.
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Where should completed applications be mailed?
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Send completed applications to:
Wyeth Pharmaceutical Assistance Foundation
P.O. Box 66762
St. Louis, MO 63166-6762 - Q.
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Once approved, how long will the patient be eligible to participate in the program?
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Patients are eligible to receive their medication through the program for a period of one year from the date of initial enrollment. After one year, patients will need to reapply to the program.
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How much medication is supplied at a time through the program?
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At any one time, the Wyeth Pharmaceutical Assistance Foundation will provide a 90-day supply of medication, with the exception of PROTONIX, for which a 60-day supply will be provided. If the health care professional specifies refills on the prescription, the health care professional can call to request refills for up to one year.
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What is the process for reapplying to the program?
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The process for reapplying is identical to the primary application process. The application forms must be completed in their entirety, including the original signatures of both the health care professional and the patient. The application must be received via mail. Once the completed application is received and participation in the program is approved, patients will be eligible to receive medication for another year. From receipt of a completed application, it takes approximately 7 to 10 days for medication to arrive at either the health care professional's office or the patient's home address.
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How will patients know when they need to reapply?
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Patients will be notified automatically approximately 60 days before they need to reapply to provide time to complete the application and to see their health care professional for a new prescription.
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Can I fax completed applications to Wyeth for processing?
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The Wyeth Patient Assistance Program does not accept faxed applications. All applications must contain original signatures and be received via mail.
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Can a health care professional call in a prescription or a refill?
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Only refills can be called in to the program. If the health care professional specifies refills on the prescription, the health care professional or patient can call to request refills for up to one year.
Before mailing an application, be sure that all information has been completed in its entirety to avoid unnecessary delays.
For information about assistance with medications not offered by the Wyeth Pharmaceutical Assistance Foundation, please contact the Partnership for Prescription Assistance at www.pparx.org or call 1-888-4PPA-NOW (1-888-477-2669).
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