The ReFacto Trial Prescription Program is sponsored by Wyeth to give eligible hemophilia A patients a free introduction to ReFacto. This program allows you and your doctor to experience first-hand what hemophilia therapy with ReFacto has to offer. Please note that if you are currently receiving ReFacto and/or have participated in past trial prescription programs, you are not eligible.

Experience Therapy With ReFacto
The Trial Prescription Program provides:

• A one-time special offer from Wyeth
• A 1- to 2-month free supply of ReFacto
• Quick and easy enrollment

How to enroll

• Complete the personal information portion of both forms and give the forms to your health care professional.
• Meet with your health care professional so that he or she can complete the enrollment form.
• Your health care professional will write a prescription for ReFacto, documenting any allergies you have and listing any other medicines you currently take.
• Your health care professional will complete the authorization form and submit it with the enrollment form via fax or mail.
• Download the Trial Prescription Program enrollment form and the authorization form.

This document is in PDF (portable document format). PDF files require Adobe® Reader®; click here to download this free program.

After you enroll
After you enroll in the ReFacto Trial Prescription Program, Dendrite^*, the program administrator, will fill your prescription and coordinate future product shipments. Someone from Dendrite will call you to confirm product delivery, and to answer any questions you have about the ReFacto Trial Prescription Program or its application process. All information you provide to Dendrite is confidential.^†

Frequently asked questions

Q.	Is there a limit to the number of people who can enroll in the ReFacto Trial Prescription Program?
A.	Yes. Wyeth has a limited number of enrollment forms available for each hemophilia treatment center (HTC) or health care professional. This number is based on the percentage of hemophilia A patients in the United States served by that particular HTC or health care professional. This allows equal access for patients to try the product and for their health care professionals to gain clinical experience with it.
Q.	How much of the product will patients receive during the ReFacto Trial Prescription Program, and what is the duration of therapy?
A.	Patients enrolled in the program will receive approximately a 1- to 2-month supply of free ReFacto. The exact amount of ReFacto supplied under the program is based on the patient's age: <1 to 5 years: 5000 IU 6 to 11 years: 10,000 IU 12 years and older: 20,000 IU
Q.	Can a patient enroll more than once in the program?
A.	No. Patients may enroll only once in the program.
Q.	How will patient confidentiality be maintained?
A.	The names of individuals who enroll in the ReFacto Trial Prescription Program will not be shared with Wyeth, except in the event of an audit, and will be used only by Dendrite, the program administrator, to arrange for product shipment.
Q.	Are more enrollment forms available if the supply runs out?
A.	Yes, enrollment forms are available through your health care professional, who can contact his or her local sales representative, but there is a limited number of enrollment forms for each HTC or health care professional.

Enroll in the ReFacto Trial Prescription Program
Ask your health care professional for an enrollment form and a patient authorization form. If he or she doesn't have them, ask the program coordinator at your HTC, or call Dendrite, the program administrator, and request that the forms be sent to your health care professional.

For more information
Please contact Dendrite at 1-800-710-1379, Monday through Friday, 9:00 a.m. to 5:00 p.m. Eastern time, if you:

• Have any questions we haven't answered
• Would like more information about the ReFacto Trial Prescription Program
• Would like to receive a Trial Prescription Program Welcome Package, including copies of the enrollment and authorization forms

All patient-specific information and correspondence should be addressed to:

ReFacto Trial Prescription Program Administrator Dendrite Interactive Marketing, LLC PO Box 1080 Wayne, NJ 07474-9801

^*Dendrite is a HIPAA-compliant provider (HIPAA is the Health Insurance Portability and Accountability Act).

^†All submitted information is for the sole use of Wyeth and its ReFacto Trial Prescription Program Administrator. Information that specifies the identity of a patient is restricted, unless required by law.

Indication
ReFacto is indicated for the control and prevention of hemorrhagic episodes and for surgical prophylaxis and for short-term routine prophylaxis to reduce the frequency of spontaneous bleeding episodes in patients with hemophilia A. The effect of regular routine prophylaxis on long-term morbidity and mortality is unknown.

Important Safety Information

	•	As with the intravenous administration of any protein product, adverse reactions may include headache, fever, chills, flushing, nausea, vomiting, tiredness, or symptoms of allergic reactions.
	•	The remote possibility exists for hypersensitivity to non-human mammalian proteins. Known hypersensitivity to mouse or hamster proteins may be a contraindication to the use of ReFacto.
	•	Allergic reactions such as hives, itching, difficulty breathing, rapid heart rate, light-headedness and anaphylaxis have been reported for all factor VIII products. Patients should discontinue use of the product and contact their health care provider immediately and/or seek emergency care if any of these symptoms occur.

Please see ReFacto Prescribing Information

The health information contained herein is provided for educational purposes only and is not meant to replace personal discussions between health care providers and patients. All decisions about patient care must be made with a health care provider who can assess the special needs of each individual patient.