Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
Scroll down to see them all.
 

View Coupon View Coupon

MyAlprolix Program

This is a copay assistance program

Provided by: Bioverativ


TEL: 855-692-5776


FAX: 855-398-7634
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Bioverativ Program Enrollment Form (Alprolix)

 

Medications

  • Alprolix powder; lyophilized (coagulation factor IX (recombinant), fc fusion protein)
 

Eligibility Requirements   

Insurance Status *Contact program for details.
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be treated by US licensed healthcare provider and use a US pharmacy
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe 2 business days, once application process is complete
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

There is a coverage limit of $12,000 per year.

Free Trial Plus Program: receive a free 30-day supply if this is your first prescription of Alprolix. Other restrictions may apply.

Bioverativ also offers the Factor Access Program, which helps with caps and gaps in your insurance, as well as Insurance Counseling. Contact program for more information.


Updated May 07, 2018


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

View Coupon View Coupon

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • Alprolix (coagulation factor IX (recombinant), fc fusion protein)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated July 10, 2018