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MyAlprolix Program

Provided by: Bioverativ

5000 Davis Drive
PO Box 13919
Research Triangle Park, NC 27709

TEL: 855-692-5776

FAX: 855-398-7634
Languages Spoken:


Program Website


Program Applications and Forms

MyAlprolix Free Trial Plus Program Enrollment Form

MyAlprolix Enrollment Form



  • 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


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


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.

MyAlprolix 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 April 19, 2018