This resource, originally compiled in 2000 by University of Florida pharmacy students Chris Fields and Andrea Ruygrok under the direction of Professor Leslie Hendeles, Pharm.D., was recently reorganized and updated by Virginia Commonwealth University pharmacy student Brandon Jennings. Now organized by drug name and manufacturer, the information is current as of July 21, 2003. (The American Society of Health-System Pharmacists is not responsible for the accuracy of the booklet's contents).
Program Details for Manufactures Providing Prescription Assistance Programs
3M Pharmaceuticals
Products:
- Maxair™ Autohaler™
- Theolair™
Program in place:Yes
Contact information:
3M Pharmaceuticals
3M Center Bldg. 275-6W-13
St. Paul, MN 55144
Phone: (800) 328-0255
Phone: (651) 733-1110 [alternate]
Fax: (651) 733-6068
Initiation
- Anyone may call for the application form
Health Provider's Role
- Pharmacist
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Must complete a part of the application form
Patient's Role
- Complete a part of the application form
Eligibility
- Must not have prescription insurance coverage
- Must not qualify for state or federal assistance with his or her prescription medications
- At or below 200% of U.S. Federal Poverty Level
- Patient must be a legal resident of the U.S. with a Social Security Number
How Dispensed
- Sent to physician
- Quantities
- Maxair™Autohaler™– 3 Autohalers™
- TheolairT™– 300 Tablets (3 100 ct. bottles)
Repeat Process
- Call must be placed to obtain another authorization form
- Patients can all in their own re-orders
AstraZeneca
Products:
- Accolate®
- Pulmicort Respules®
- Rhinocort®
- Pulmicort Turbuhaler®
Program in place:Yes
Contact Information
AstraZeneca Foundation Patient Assistant Program
P.O. Box 15197
Wilmington, DE 19850-5197
Phone: (800) 424-3727
Phone: (800) 698-0085 [alternate – pharmacy that dispenses medications for program]
Initiation
- Anyone can call for the application form
Health Provider's Role
- Pharmacist
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Must complete part of application form and sign
Patient's Role
- Must provide detailed financial and insurance information
- Must sign form
- Provide $5 shipping and handling fee
Eligibility
- Determined by
- Monthly income
- Assets
- Lack of private insurance carrier
- Must be a legal U.S. resident with a social security number
How dispensed
- 90-day supply
- Able to be sent to physician or patient via USPS
Quantities
- Accolate® - 180 tablets (3 60 ct. bottles)
- Pulmicort Respules® - 90 respules (3 30 respule boxes)
- Pulmicort Turbuhaler® - 600 metered doses (3 200 metered devices)
- Rhinocort Aqua® - 120-day supply (i spray per nostril qd)
Repeat process
- Original application is valid for one year
- Patient will automatically be notified before the end of one year to renew the process
Aventis Pharmaceuticals
Products
- Allegra®
- Allegra® -D
- Azmacort®
- Nasacort®
- Nasacort AQ®
Program in place: Yes
Contact information
Patient Assistance Program
P.O. Box 759
Somerville, NJ 08876
Phone: (800) 221-4025
Phone: (800) 207-8049 [alternate]
Initiation
- Anyone can call to have application form mailed or faxed to physician
Health Provider's Role
- Pharmacist
- Can call to have application form sent to physician
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Must complete application form
- Send back to company
Patient's Role
- Attach copy of most recent Federal tax return
- If patient does not file taxes, other proof of annual income must be supplied
Eligibility
- Patient must be a legal U.S. resident
- Cannot have or qualify for any prescription coverage under Medicare, Medicaid, Veteran's Administration, or any state or local programs
- Patient's annual household income must be below the "Aventis Poverty Level" (chart available when application is requested)
How Dispensed
- Maximum of a 90-day supply
- Sent to physician's office
- Allow 4 weeks for delivery
- Quantities
- Allegra® – 100 ct. bottle
- Allegra® -D – 100 ct. bottle
- Azmacort® Inhalation Aerosol – 1 canister
- Nasacort® Nasal Inhaler – 1 canister
- Nasacort AQ® Nasal Spray – 1 canister
Repeat Process
- Must send in application form with new prescription every 3 months
Boehringer Ingelheim Pharmaceuticals
Products
- Alupent® Nebulizer Solution
- Atrovent® MDI
- Combivent® MDI
Program in place: Yes
Contact information
Boehringer Ingelheim Cares Foundation, Inc.
c/o Express Scripts Specialty Distribution Services, Inc.
P.O. Box 66555
St. Louis, MO 63166-6773
Phone: (800) 556-8317
Phone: (203) 798-9988 [alternate]
Initiation
- Anyone can call for the application form
Health Provider's Role
- Pharmacist
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Complete part of the application form
- Provide a prescription
- Submit to company
Patient's Role
- Must provide income and insurance information
- Company prefers tax returns/W2 forms for income documentation
- Visa if the patient is a non-U.S. citizen
How Dispensed
- Maximum of a 90-day supply
- Sent to physician
Repeat Process
- Must submit copy of original application form with new prescription every 3 months
- Original application form is valid for 1 year
- After 1 year
- Process must be started over
Forest Pharmaceuticals, Incorporated
Products
- Aerobid® Inhaler
- Aerobid® M Inhaler
- Aerochamber®
- Aerochamber® Mask
- TheochronTM
Program in place: Yes
Contact Information
Patient Assistance Program
13600 Shoreline Drive
St. Louis, MO 63045
Phone: (800) 851-0758
Phone: (314) 493-7000 [alternate]
Fax: (314) 493-7452
Initiation
- Anyone may call for the application form
Health Provider's Role
- Pharmacist
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Must complete form
- Attach prescription
- Must mail application to company
- No faxes, e-mails or photocopies will be accepted
Patient's Role
- Must provided detailed financial and insurance information for the household
- Must sign form
How dispensed
- 90-day supply of drug or device
- Sent to licensed practitioner
- Allow 6 weeks for delivery
- Quantities
- Aerobid® Inhaler – 7 g canister
- Aerobid® M Inhaler – 7 g canister
- Aerochamber® – N/A
- Aerochamber® Mask – Sm, Reg, Lg
- TheochronTM – 100 ct. bottle
Repeat Process
- Application form with new prescription must be mailed to the company every 90 days
GlaxoSmithKline, Incorporated
Products
- Advair™ Diskus®
- Beconase AQ®
- Flonase®
- Flovent®
- FloventÒ Rotadisk®
- Serevent® MDI
- Serevent® Diskus®
- Ventolin®
- Ventolin® HFA
Program in place: Yes
Contact information
Bridges to Access
P.O. Box 29038
Phoenix, AZ 85038-9038
Phone: (866) 728-4368
Web: bridgestoaccess.gsk.com
Initiation
- Physician or patient advocate* can obtain the application form at www.bridgestoaccess.com
- After application form is completed, physician or patient advocate must call the company to
- Give enrollment information
- Wait for approval
Health Provider's Role
- Pharmacist/Physician/Patient Advocate
- Able to help fill out the application form
- Able to obtain conformation over the phone
- Must mail to GlaxoSmithKline within 20 days of approval
- Notify GSK if patient is no longer on the same medication therapy
- Patient's Role
- Must provide insurance and proof of income
Eligibility
- Must be a legal U.S. resident
- Cannot qualify for prescription medication coverage with any public or private insurance/assistance carrier
- Income cannot be greater than
- $25 000 if a single member household, or
- 250 % of poverty level if a multi-member household
How Dispensed
- Immediate 60-day supply coupon given to patient after approval process is complete
- Coupon entitles patient to receive medication for $5-co-pay per fill
- Patient gives coupon to pharmacist
- After enrollment form is processed, patient can be approved for two additional 90-day supplies of the medication by mail
- Approximately two weeks before the first 90 days have surpassed, the patient must call (866) 728-4368 to request second 90-day supply be sent
- Patient is eligible to participate for six months (can be extended to 12 months if needed, as approved by the patient advocate)
- Advocate will be notified approximately 30 days before termination to request re-authorization
- Advocate must notify GSK at (866) 728-4368 if patient is no longer on the same medication therapy
*patient advocate must be someone involved in the direct care of the patient; cannot be a family member or friend of the patient
Merck & Company, Incorporated
Products
Program in place: Yes
Contact information
Merck Patient Assistance Program
P.O. Box 690
Horsham, PA 19044-9979
Phone: (800) 994-2111
Phone: (800) 727-5400 [alternate]
Initiation
- Applications are mailed out in bulk (qnty. 25)
- Preferable for pharmacist or physician to call for applications and display in pharmacy or office
Health Provider's Role
- Pharmacist
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Complete part of the application form
- Provide a prescription
- Submit to company (unstapled)
Patient's Role
- Provide financial information
- Sign the form
Eligibility
- Must live in the United States and have a prescription from a doctor licensed in the United States for a Merck medication
- Cannot have insurance or other coverage for prescription medications
- Must exhaust all other options
- HMOs, Medicaid, Medicare, state pharmacy assistance programs, Veteran's assistance, etc.
- Income cannot be greater than
- $18 000 if a single member household, or
- $24 000 if a two member household, or
- $35 000 if a four member household
** if special circumstance apply, the physician may request for an exception to be made**
How Dispensed
- 90-day supply with a maximum of 3 refills
- Sent to patient's home unless otherwise indicated by the physician
- Approval is granted for a maximum of 1 year
Pfizer Incorporated
Products
Program in place: Yes
Contact information
Pfizer Connection to Care Program
P.O. Box 66585
St. Louis, MO 63166-6585
Phone: (800) 707-8990
Phone: (800) 438-1985 [alternate]
Initiation
- Anyone can call to obtain the guidelines for the program
Health Provider's Role
- Pharmacist
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Will need to send a letter on official letterhead stationary
- Must include specific information
- By mail only
- Will need to attach prescription
Patient's Role
- Must provide insurance information
Eligibility
- Must be a legal U.S. resident
- Cannot qualify for prescription medication coverage with any public or private insurance/assistance carrier
- Income cannot be greater than
- $16 000 if a single member household, or
- $25 000 if a family household
How Dispensed
- 90-day supply
- Sent to physician
Repeat Process
- Re-apply every three months
- Tax return and income documentation only needs to be supplied once every year
Schering Labs/Key Pharmaceuticals
Products
- Foradil® Aerolizer™ (in US, non-US made by Novartis)
- Proventil® MDI
- Proventil® HFA
- Proventil® Nebulizer Solution
Program in place: Yes
Contact information
Schering Lab/Key Pharmaceuticals Patient Assistance Program
P.O. Box 52122
Phoenix, AZ 85072
Phone: (800) 656-9485
Phone: (800) 222-7579 [alternate]
Initiation
- Physician or patient advocate may request the application form be sent
- Application form must be original
Health Provider's Role
- Pharmacist
- Can have application form faxed to pharmacy, filled out by patient and then have patient transport form to physician
- Physician
- Must complete and sign the application form
- Must provide written prescription
Patient's Role
- Must complete the application form
- Must provide proof of monthly income
Eligibility
- If the patient has no income
- Physician or social worker must indicate this on company letterhead
- Cannot qualify for prescription medication coverage with any public or private insurance/assistance carrier
How Dispensed
- 90-day supply
- Sent to physician's office
Repeat Process
- Reorder form will be included with the approval letter
No program in place
- Abbott Laboratories - Zyflo®
- Dey Laboratories – Albuterol MDI, Albuterol Nebulizer Solution, Easivent® Spacer
- Muro Pharmaceuticals, Inc. - Prelone® , Volmax® (out of business)
- Mylan Laboratories, Incorporated – Albuterol
- Purdue Frederick - Uniphyl® (samples program)
- Roxane Laboratories – Prednisone
- Sepracor - Xopenex®
- Wyeth Laboratories – Albuterol Tablets