| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 3. Scroll down to see them all. |
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CSL Behring Support & Assistance ProgramsThis program provides brand name medications at no or low cost |
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Provided by: CSL Behring |
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TEL: 844-727-2752 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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CSL Behring Support & Assistance Programs Forms: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| Since drug availability changes based on inventory, call to make sure requested drug is available. |
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| Updated August 25, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 3. Scroll down to see them all. |
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Prolastin Direct ProgramThis program provides brand name medications at no or low cost |
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Provided by: Grifols |
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c/o Eversana TEL: 800-305-7881FAX: 866-588-6940 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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Prolastin Direct Prescription and Enrollment Form/SMN
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Prolastin Direct Healthcare Processionals Electronic Enrollment |
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Prolastin Direct Program Brochure |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 for information or inform doctor that he/she is in need | ||
| Decision Communicated | Not specified | ||
| Decision Timeframe | Not specified | ||
Medication |
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| 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 |
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| Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients. |
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| Updated September 08, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 3. | |||
Zemaira ConnectThis program provides brand name medications at no or low cost |
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Provided by: CSL Behring |
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TEL: 866-936-2472ALT PHONE: 844-727-2752 FAX: 855-829-5365 |
Languages Spoken:
English |
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Program Applications and Forms |
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Zemaira Connect Request Form |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| 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. |
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| Updated August 25, 2023 | |||
