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

MyEloctate Program

Provided by: Bioverativ

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

TEL: 855-693-5628

FAX: 855-398-7634
Languages Spoken:

Program Website


Program Applications and Forms

MyEloctate Program Enrollment Form

MyEloctate Free Trial Plus Program Enrollment Form



  • antihemophilic factor (recombinant), fc fusion protein injection (Eloctate) Injection

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

Updated January 29, 2018