Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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CSL Behring Support & Assistance Programs

This program provides brand name medications at no or low cost

Provided by: CSL Behring


TEL: 800-676-4266


Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

CSL Behring Support & Assistance Programs Forms: Contact program

 

Medications

  • alpha1-proteinase inhibitor human injection; iv (Zemaira) Injection; IV
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Contact program for details.
Income Based on FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or download
Receiving Varies
Returning Fax from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Varies
   

Medication

Amount/Supply Contact the program for more details.
Sent To Varies
Delivery Time Varies
Refill Process Varies per medication
Limit Varies
Re-application Varies
   

Additional Information

Since drug availability changes based on inventory, call to make sure requested drug is available.

Updated August 01, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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Prolastin Direct Program

This program provides brand name medications at no or low cost

Provided by: Grifols

c/o Eversana

TEL: 800-305-7881


FAX: 866-588-6940
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Prolastin Direct Prescription and Enrollment Form/SMN

Prolastin Direct Program Brochure

 

Medications

  • alpha1-proteinase inhibitor human solution; iv (Prolastin-C) Solution; IV
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be a US resident and treated by a US licensed healthcare provider
   

Application

Obtaining Call, download or apply online
Receiving Complete online, download from website or faxed.
Returning Fax or submit online
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Call or enroll online
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Patient's home
Delivery Time Not specified
Refill Process Not specified
Limit Contact the program for details
Re-application New application yearly
   

Additional Information

Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.

Updated June 01, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

Zemaira Connect

This program provides brand name medications at no or low cost

Provided by: CSL Behring


TEL: 866-936-2472


ALT PHONE: 844-727-2752
FAX: 855-829-5365
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Zemaira Connect Request Form

 

Medications

  • alpha1-proteinase inhibitor human injection; iv (Zemaira) Injection; IV
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Contact program for details.
Income Based on FPL
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be residing in the US or US territory
   

Application

Obtaining Call or download
Receiving Faxed, emailed, mailed or downloaded
Returning Fax from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Varies
Delivery Time Contact Program for Details
Refill Process Contact program for details.
Limit Contact the program for details
Re-application Contact program for details.
   

Additional Information

Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.

Program provides medically necessary therapy to qualified individuals who are uninsured, underinsured, or unable to afford their therapy.

Updated August 01, 2022